CCM  LIBRARY 


CALIFORNIA  COLLEGE  OF  MEDICINE 


<>^$«K>4''^^^^<^^K>44•4••^^ 


AS  A 

THERAPEUTIC  AGENT 


BY 

PROFESSOR  DR.  AUGUST  BIER 

OF  THE  UNIVERSITY  OF   BONN 


AUTHORIZED  TRANSLATION 
EDITED  BY 

DR.  GUSTAVUS  M.  BLECH 

CONSULTING  SURGEON,  PEOPLE'S  HOSPITAL,  CHICAGO 
LATE  PROFESSOR  OF  SURGERY,  JENNER  MEDICAL  COLLEGE 


WITH  ELEVEN  ILLUSTRATIONS 


CHICAGO 

A.  ROBERTSON  &  CO. 

1905 


13  r?fr  L 


COPYRIGHT.  1905. 

BY  A.  ROBERTSON  &  CO. 

CHICAGO 


W.  B.  CONKEY   COMPANY 

CHICAGO 


TO 

PROFESSOR  CARL  BECK,  M.  D. 

OF   NEW  YORK 
THIS  TRANSLATION   IS  DEDICATED 

BY 
THE  EDITOR 

AS  A  TOKEN  OF  APPRECIATION 

OF  HIS  SERVICES  RENDERED  THE 

SCIENCE  OF  SURGERY 


CONTENTS 


PAGE 

EDITORIAL  NOTE '7 

INTRODUCTORY 9 

A.  GENERAL  PART. 

CHAPTER 

I.     In    all    Important  Phenomena  of  Life  Hyperemia  is 

Present 21 

II.     Artificial  Production  of  Hyperemia 24 

III.  Production  of  Active  Hyperemia 25 

IV.  Apparatus  for  Treatment  with  Hot  Air , 39 

V.     Local    and    General    Influence  of   Hot-Air  Baths  on 

the  Body 46 

VI.     Production  of  Passive  Hyperemia 51 

VII.     Passive    Hyperemia  of    the   Extremities  by  a  Stasis 

Bandage 56 

VIII.     Hyperemia  by  Suction  Apparatus 74 

IX.     Hyperemia  by  Dry  Cupping 86 

X.     Other    Agents    for    the     Production   of    Hyperemia. 

"Derivantia  " 88 

XI.     Influence  of  Hyperemia  on  the  Lymph- Current., 101 

B.  GENERAL  EFFECTS  OF  HYPEREMIA. 

CHAPTER 

XII.  Analgesic  Effects  of  Hyperemia 107 

XIII.  Bactericidal  Effect  of  Hyperemia 110 

XIV.  Absorptive  Effect  of  Hyperemia 123 

XV.  Solvent  Effect  ot  Hyperemia 133 

XVI.     Nutritive  Effect  of  Hyperemia 139 

C.  SPECIAL  PART. 

CHAPTER 

XVII.     Treatment  of  Diverse  Diseases  with  Hyperemia 175 

XVIII.     Treatment  of  Tuberculosis 177 

XIX.     Treatment  of  Acute  and  Subacute  Arthritis 199 

XX.    Treatment  of  Other  Forms  of  Acute  Inflammation 209 

XXI.     Treatment  of  Chronic  Stiff  Joints 214 

XXII.     Hyperemia  as  an  Absorptive  Agent 220 

XXIII.  Treatment  of  Neuralgias  and  Other  Pains  by  Hyper- 
emia   223 

XXIV.     Use  of  Hot  Air  in  Diseases  of  the  Blood-Vessels 225 

CONCLUSION -. 227 

BIBLIOGRAPHIC   REFERENCES..  .  229 


EDITORIAL   NOTE 


In  presenting  to  the  English-speaking  profession  a 
translation  of  Prof.  Bier's  monograph,  the  editor  feels 
that  he  has  rendered  his  colleagues  a  service.  He  leaves 
it  to  the  reader  to  judge  of  its  merits  and  only  adds  that 
the  author's  remarks  contained  in  his  "Conclusion" 
should  be  read  first,  for  it  really  is  a  preface. 

Thousands  of  physicians  in  this  country  have  treated 
many  cases  with  artificially  produced  active  hyperemia 
without  being  able  to  give  scientific  reasons  for  what- 
ever successes  or  failures  they  may  have  had  with  it, 
Though  the  editor  was  probably  one  of  the  first,  if  not 
the  first,  in  this  country  to  use  active  hyperemia  on 
a  large  scale  and  to  contribute  several  articles  to  con- 
temporaneous medical  literature  and  though  he  has  fol- 
lowed the  subject  with  great  interest,  he  must  admit  that 
he  was  so  overwhelmed  by  the  vast  information  con- 
tained in  Bier's  work  that  it  was  sheer  enthusiasm  which 
prompted  him  to  translate  and  edit  the  book  for  his 
American  colleagues. 

Prof.  Bier,  a  former  pupil  of  v.  Esmarch,  to  whom 
the  original  work  is  dedicated,  is  one  of  the  younger 
surgeons  who  have  become  famous  on  account  of  their 
original  researches.  A  master  mind  like  his  would 
give  us  nothing  but  what  would  prove  useful  to  our 
science  and  to  suffering  humanity.  One  need  only 
read  his  introduction  to  realize  that  here  is  an  authority 
whose  keen  philosophical  insight,  whose  learning  is  ex- 
ceeded only  by  his  love  for  his  suffering  fellow-man. 
And  here  it  is  that  he  is  in  sympathy  with  American 
medical  men  who  long  ago  came  to  the  conviction  that 
after  all  medicine  for  science'  sake  is  useless,  that  our 
profession  derives  its  splendor  and  glory  from  the  fact 
that  above  all  else  it  is  humanitarian  in  character. 

One  case  in  the  editor's  practice  will  convince  the 
readers  of  the  good  he  has  derived  from  the  book.  He 
was  called  to  attend  a  recently  married  woman  who  for 


8  EDITORIAL  NOTE 

five  weeks  had  suffered  excruciating  pain  from  an  acute 
inflammation  of  the  right  elbow-joint.  Nothing  did  her 
any  permanent  good,  so  that  the  two  attending  physi- 
cians decided  that  an  operation  was  necessary,  when  the 
editor  was  called  in.  A  diagnosis  of  gonorrheal  arthritis 
was  made.  The  husband  admitted  previous  infection. 
Gonococci  were  found  in  the  discharge  taken  from  the 
uterus.  The  suffering  of  the  patient  and  the  mental 
agony  of  the  husband  can  hardly  be  described.  Passive 
hyperemia  was  tried  with  so  striking  improvement  that 
all  thought  of  an  operation  has  been  abandoned  by  all  con- 
cerned. Thus  a  piece  of  rubber  tubing  was  the  means  of 
preventing  a  mutilating,  more  or  less  dangerous  opera- 
tion !  And  the  credit  is  solely  due  to  the  author  of  this 
work,  which  hereby  is  gratefully  acknowledged. 

That  is  why  the  editor  sat  up  long  after  midnight  for 
many  weeks  impelled  by  his  desire  to  convey  to  others 
the  information  which  has  proved  so  useful  to  him. 

Attention  is  called  to  the  German  word  "Zweckmassig- 
keit,"  for  which  the  editor  selected  the  English  words 
"purposiveness"  and  "rationale"  as  he  saw  fit. 

In  giving  the  degrees  of  temperature  in  centigrade  a 
personal  inclination  has  been  followed.  The  Fahrenheit 
scale  is  unscientific  and  superannuated. 

Chapter  IV.  contains  a  short  resume  of  the  original 
and  has  been  rewritten  to  suit  the  needs  of  American 
medical  men. 

The  numbers  in  the  text  in  brackets  refer  to  the  same 
number  in  the  ''Bibliographic  References,"  which  appear 
at  the  end  of  the  work. 

The  editor  herewith  expresses  his  thanks  to  Mr.  Carl 
Friedrich  Lampe,  of  Leipsic,  the  publisher  of  the  German 
work,  for  courtesies  shown  him  and  to  Dr.  Carl  Theo- 
dore Gramm  for  many  suggestions  and  revision  of  the 
manuscript. 

GUSTAVUS  M.  BLECH. 
Chicago,  January,  1905. 


INTRODUCTORY 


It  is  not  so  very  long  ago  when  not  only  theologians 
and  a  large  number  of  philosophers  and  naturalists  but 
also  many  physicians  thought  teleologically.  In  all  proc- 
esses which  they  observed  in  man  during  health  and 
disease  they  asked  themselves :  why  do  they  occur  and  of 
what  use  are  they  to  the  organism?  This  teleologic  con- 
ception was  at  all  times  deeply  rooted  in  the  minds  of 
the  people.  Proof  for  this  is  found  in  the  ancient  idea 
that  disease  is  a  fight  of  the  body  against  an  intruded 
enemy,  which,  depending  on  the  victory  of  the  former  or 
latter,  terminates  in  recovery  or  death,  and  also  in  the 
view  held  by  laymen  even  to  this  ,day  that  fever,  inflam- 
mation, suppuration,  diaphoresis,  expectoration  and 
diarrhea  serve  to  remove  from  the  body  "noxious  and 
impure  matter." 

I  will  endeavor  to  show  that  a  teleologic  standpoint  is 
not  only  rational  and  justified  but  even  essential  for  the 
observation  of  things  in  animated  nature.  However, 
these  teleologists  overreached  their  mark.  To  begin  with, 
they  committed  an  error  in  defending  the  so-called 
anthropocentric  teleology.  Man  was  put  in  the  center 
of  the  universe  and  for  his  personal  benefit  everything 
has  been  created.  It  is  for  him  only  that  the  sun  shines 
and  the  rain  falls ;  animals  and  plants  have  been  created 
to  serve  him  as  food ;  for  his  delight  only  nature  has  been 
made  so  beautiful  and  magnificent.  .  Justly  this  kind  of 
teleology  became  the  subject  of  ridicule  when  it  went  so 
far  as  to  explain  the  ripening  of  cherries  in  summer  "in 
order  than  man  should  have  his  refreshment  in  the  warm 
"season."  Even  the  older  philosophy  opposed  this 
vehemently.  But  it  was  principally  Darwin's  teaching 
which  dealt  it  the  death-blow.  Darwin  did  not  lift  man 
from  the  rest  of  nature  to  put  him  over  it,  but  placed 
him  within  it  and  permitted  him  to  be  only  one  of  the 
innumerable  phenomena  of  nature,  of  whom  one  did  not 

9 


10  INTRODUCTORY 

even  know  whether  he  would  not  be  replaced  by  some- 
thing better  and  more  perfect  in  the  course  of  tremen- 
dous spaces  of  time. 

These  older  teleologists  again  erred  in  that  they  did 
not  recognize  the  purposiveness  in  nature  as  a  simple 
matter  of  fact  but  established  it  as  an  explanation  for  all 
possible  phenomena.  They  did  not  trouble  themselves 
to  inquire  into  the  deeper  causes  of  things  but  simply 
said :  This  is  so  and  not  otherwise,  this  becomes  so  and 
not  otherwise  because  so  it  is  rational.  Naturally  such  a 
system  is  most  defective  and  apt  to  obstruct  scientific 
progress.  It  is,  therefore,  not  to  be  wondered  at  that 
with  the  application  of  exact,  scientific  inquiry  in  medi- 
cine, these  doctrines  became  ill-reputed.  And  then  it 
happened,  as  it  usually  does  when  reaction  follows  col- 
lapsing, axiomatic  views — with  the  decadence  of  the 
doctrine  the  good  kernel  too  was  dropped,  and  even 
to-day  the  practical  physician  who  confesses  to  hold  such 
teleologic  views,  as  we  shall  discuss,  is  in  danger  of 
being  called  obsolete  by  such  of  his  professional  col- 
leagues who  consider  themselves  exact  and  scientific 
investigators. 

If  these  people,  however,  would  become  a  little  more 
familiar  with  biology,  which  must  be  considered  the 
foundation  of  practical  medicine,  if  the  latter  is  to  rank  as 
a  science,  it  is  they  who  would  find  themselves  to  be  the 
backnumbers.  To  be  sure,  biology  ignores  the  great  fun- 
damental problem,  whether  the  universe  and  man  has  an 
object,  a  problem,  which,  as  long  as  thinking  man  will 
exist,  stirs  and  will  stir  the  mind,  and  which  undoubtedly 
never  will  be  solved,  and  leaves  it  to  the  philosopher  and 
theologian.  Though  it  was  Darwin's  teaching,  which 
dominates  modern  biology,  that  most  effectively  did 
away  writh  the  naive  anthropocentric  teleology,  and 
though  a  large  number  of  Darwinists  at  first  declined  to 
entertain  each  and  every  teleologic  conception,  they 
soon  became  converted  and  acknowledged  that  their 
idea  lacked  logic.  Because,  after  all,  the  -very  nature  of 
their  teaching  demands  of  their  followers  to  be  con- 
vinced teleologists  in  regard  to  the  individual  organism 
and  the  species,  and  that  even  of  those  who  otherwise 
deny  purpose  in  nature  and  who  declare  that  all  phe- 


INTRODUCTORY  11 

nomena  in  nature — including  man — are  but  consequences 
of  certain  forces  of  nature.  For  only  a  rationally  con- 
structed organism,  adapted  in  every  direction  to  the 
external  conditions,  can  maintain  the  struggle  for  exist- 
ence while  nature  itself  removes  everything  irrational. 

A  large  number  of  Darwin's  strict  adherents  have 
expressed  themselves  thus  and  have  acknowledged  them- 
selves as  teleologists  by  conviction.  Some  (i)  over- 
reaching their  mark  even  asserted  that  it  was  Dar- 
win's teaching  which  first  brought  to  light  and  rendered 
comprehensible  this  limitation  of  purposiveness  to  ani- 
mated phenomena  of  nature.  However,  naturalists  and 
philosophers  of  entirely  different  schools  have  thought 
similarly.  Thus  Kant,  in  his  Criticism  of  Teleologic 
Judgment,  discusses  the  "inner"  purposiveness  of  the 
organisms  while  strongly  opposing  the  anthropocentric 
and  "outer"  teleology.  His  teleology,  like  that  of  Dar- 
win, is  free  from  the  transcendental,  for  "the  manner  of 
mechanical  explanation  is  not  excluded  by  the  teleologic, 
as  if  they  contradicted  each  other." 

Even  among  medical  men  the  pure  naturalists,  anato- 
mists and  physiologists  unreservedly  acknowledge  man's 
"inner  purposiveness"  of  Kant  and  of  the  Darwinists. 
Each  anatomist  when  discovering  a  new  part,  each 
physiologist  when  unearthing  a  new  activity  in  the  body, 
asks  himself:  Why  is  it  there  and  of  what  use  is  it  to 
the  organism?  And  he  who  would  think  otherwise  would 
justly  be  considered  a  peculiar  crank.  The  few  remain- 
ing embryological  data  of  the  normal  man  which  can  not 
be  placed  in  the  category  of  purposiveness  prove  nothing 
against  the  validity  of  this  general  rule. 

Things  are  apparently  different  and  more  complicated 
in  practical  medicine  which  concerns  itself  with  the  sick 
body  and  its  cure.  The  single  fact  that  the  body  is  very 
frequently  attacked  by  disease  and  that  it  is  able,  without 
the  aid  of  a  physician  or  artificial  means,  to  effect  a  more 
or  less  perfect  cure  of  the  majority  of  diseases,  should  con- 
vince the  physician  of  the  presence  of  rational,  natural 
healing  processes.  It  is  evident  that  this  ability,  because 
it  leads  to  a  cure  of  the  disease  for  the  welfare  of  man, 
can  but  have  the  character  of  inner  purposiveness. 

It  is  clear  to  everyone  that  the  body,-  under  many 


12  INTRODUCTORY 

obnoxious  influences,  immediately  resorts  to  rational 
means  in  order  to  remove  them.  No  one  will  doubt  that 
the  violent  cough  which  expels  a  foreign  body  lodged  in 
the  larynx,  the  intense  vomiting  which  ejects  caustic 
acids  and  alkalis,  the  profuse  effusion  of  tears  and  the 
lively  spasm  of  the  eyelids  removing  irritating  bodies 
lodged  in  the  eye,  are  highly  rational  arrangements.  And 
yet  these  means  of  rescue,  as  represented  by  a  violent, 
attack  of  coughing  and  terrible  vomiting,  are  so  dis- 
agreeable to  the  injured  man  and  look  so  threatening  in 
character,  that  the  naive  observer,  were  he  ignorant  of 
the  real  injury,  would  look  upon  them  as  the  real  disease, 
whereas  in  reality  they  mean  a  warding  off  of  the  evil. 

In  those  cases  the  size  of  the  injurious  agent  makes  it 
easily  perceptible  to  our  senses  and  thus  protects  us 
against  coming  to  so  fatal  and  false  a  conclusion.  This 
was  not  always  the  case  when  the  injurious  agent  is  so 
small  and  hidden  that  it  could  not  be  perceived  at  all  or 
only  through  a  microscope,  as  in  the  infectious  diseases. 
Even  to-day  the  majority  of  medical  practitioners  look 
upon  the  fever  and  inflammation,  which  follow  certain 
infections  as  promptly  as  a  cough  does  when  a  foreign 
body  becomes  lodged  in  the  larynx,  as  something  obnox- 
ious which  must  be  combated,  and  it  is  not  so  very  long 
ago  that,  with  few  exceptions,  all  reasoned  in  this  man- 
ner. It  is  indeed  noteworthy  that  just  in  our  time,  in 
which  so  much  labor  and  acumen  is  spent  in  the  analysis 
of  disease  into  the  real  causative  factor  and  in  life- 
processes  by  which  the  body  responds  to  the  injury,  we 
have  but  lately  begun  to  draw  the  logical  conclusion  from 
that  which  we  have  recognized.  Modern  research  has 
been  eminently  successful  in  the  incorporation  of  pathol- 
ogy among  biological  sciences  and  has  taught  us  that  a 
considerable  portion  of  the  so-called  disease-symptoms 
are  life  phenomena,  which  appear  with  the  regularity  of 
a  natural  law ;  in  other  words,  that  disease  is  life  adapted 
to  altered  circumstances.  This  question  now  presents 
itself:  Is  it  possible  that  the  body,  in  whose  phenomena 
of  life  during  health  we  are  accustomed  to  observe  the 
most  astonishing  purposiveness,  functionates  irrationally 
during  sickness?  We  must  confess  that  in  spite  of  all 
the  newly  acquired  knowledge  we  have  gone  backward, 


INTRODUCTORY  13 

for  though  the  older  physicians  did  not  command  the 
grand  naturalistic  experience  and  equipment  we  call 
ours,  a  natural  instinct  has  led  them  on  the  track  now 
generally  conceded  to  be  the  right  one.  Who  does  not 
know  the  much  cited  axiom  of  Hippocrates :  "Fever  puri- 
fies the  body  through  fire?"  And  how  much  labor  has  it 
cost  to  gain  adherents  to  this  view,  so  modified  as  to  be 
adapted  to  our  modern  conceptions !  Whoever  wants  to 
be  convinced  in  this  need  only  read  the  great  amount  of 
literature  on  fever  which  has  accumulated  during  the  last 
half  century. 

A  similar  fate  to  that  of  the  fever  has  befallen  inflam- 
mation. After  several  older  physicians  had  recognized 
inflammation  as  a  useful  process  J.  Hunter  (2),  a  teleol- 
ogist,  appeared  as  a  zealous  defender  of  this  view.  He 
especially  emphasizes  this  in  a  chapter  which  deals  with 
the  usefulness  and  purpose  of  adhesive  inflammation  and 
in  which  he  maintains  the  idea  that  in  a  wise  way  nature 
has  provided  the  body  with  rational  means  of  self-defense. 

According  to  Neumann  (3),  S.  W.  Sachs,  in  the  begin- 
ning of  the  fourteenth  century,  framed  the  views  then 
held  on  inflammation  in  these  words :  "It  represents  a. 
reaction  of  the  organism  for  the  restoration  and  assertion 
of  its  integrity  with  increased  expenditure  of  force  of  all 
systems." 

That  the  doctrine  of  the  purposiveness  of  inflammation 
has  been  deserted  especially  during  the  last  decades  needs 
no  further  substantiation.  For  almost  all  practitioners 
recognized  to-day  as  leaders  in  their  profession  have  been 
educated  as  "antiphlogists,"  who  should  combat  the 
obnoxious  inflammatory  processes,  and  a  large  majority 
still  cling  to  this  view. 

Of  late,  however,  a  great  change  becomes  noticeable. 
The  usefulness  of  the  inflammatory  processes  has  been 
asserted  by  many  authorities.  The  merit  to  have 
brought  to  recognition  this  doctrine  and  to  have  placed 
it  on  a  scientific  basis  belongs  to  Leber  (4),  Neumann 
(5),  Marchand  (6),  Buchner  (7)  and  Metschnikoff  (8). 
and  one  will  not  be  amiss  in  saying  that  it  will  soon 
regain  supremacy  at  least  in  theoretic  medicine,  though 
the  majority  of  pathologists,  as  Marchand  puts  it,  "have 


14  INTRODUCTORY 

not  yet  freed  themselves  from  the  conception  that  inflam- 
mation is  a  deleterious  phenomenon  per  se." 

On  the  Other  hand,  a  third  life  phenomenon  of  the 
diseased  body,  viz.,  congenital  and  acquired  immunity 
against  infectious  diseases,  has  been  accorded  almost 
unlimited  recognition  as  a  useful  protective  measure  of 
the  body.  It  is  useless  to, attempt  to  discuss  these  things 
in  the  limited  space  of  an  introductory,  especially  since 
they  are  as  known  to  every  physician  as  to  their  discov- 
erer, having  aroused  a  lively  interest  even  beyond  medical 
circles.  Though  the  theories  of  anti-bodies,  alexines,  etc., 
are  still  assailable  and  unsatisfactory,  and  though  it  can 
rightly  be  said  that  we  are  yet  far  from  really  under- 
standing these  natural  healing  processes,  the  facts  never- 
theless remain  solid.  And  what  must  be  plain  to  every- 
body is  the  really  astounding  purposiveness  of  them : 
The  very  producers  of  infection  which  poison  and  decom- 
pose the  body  mobilize  the  fighting  agents  of  the  body  by 
which  their  toxines  are  rendered  harmless  and  they  them- 
selves are  killed. 

Thus  we  recognize  in  all  processes  of  reaction  occurring 
in  the  body  in  infectious  diseases  the  truth  of  Pflueger's 
(9)  saying:  "The  injury  is  the  cause  of  the  removal  of 
the  injury."  In  his  "teleologic  causal  law"  this  genial 
man  said :  "The  cause  of  each  necessity  of  a  living  being 
is  at  once  the  cause  of  the  gratification  of  this  necessity." 

Similar  views  are  contained  in  Ehrlich's  "side-chain 
theory"  on  the  development  of  anti-bodies,  a  theory 
which  has  been  much  recognized  and  much  opposed. 

No  matter  what  we  may  think  of  the  theory,  the  basic 
thought  that  poisonous  action  and  protective  action  are 
practically  one  and  the  same  must  be  recognized  as  ingen- 
ious and  fruitful. 

It  has  generally  been  acknowledged  that  the  infectious 
diseases  have  awakened  in  us  the  knowledge  that  the 
body  itself  possesses  rational  healing  agents.  To  admit 
this  but  for  one  group  of  diseases  is  one-sidedness,  for 
an  evidently  general  axiom  in  nature  can  not  concern  one 
kind  of  diseases  only.  Interest  nowadays  is  so  promi- 
nently centered  in  the  infectious  diseases  that  after  a 
perusal  of  the  newer  literature  on  general  pathology  one 
might  come  to  the  conclusion  that  the  other  diseases 


INTRODUCTORY  15 

and  deformities  must  step  aside,  while  in  reality  these 
diseases  represent  only  a  part — though  a  very  large  one 
— of  the  diseases. 

And  we  c^in  also  see  in  other  diseases  how  the  body 
most  perfectly  removes  sustained  injuries,  replaces  them 
or  at  least  mends  them.  I  need  only  remind  of  what  we 
surgeons  expect  from  nature.  After  all,  surgery  in  many 
directions  is  a  mutilating  art.  We  destroy  the  beautifully 
and  ingeniously  constructed  joint  and  out  of  the  remain- 
ing bone  stumps  and  soft  parts  expect  a  new,  imperfect 
yet  functionating  joint ;  we  ligate  the  main  artery  of  a 
limb  in  the  assumption  that  the  blood  will  seek  the  most 
tangled  side  passages  in  the  affected  territory  until  in  a 
surprisingly  short  time  an  insignificant  branch  grows  to 
be  a  main  artery. 

These  examples  could  be  multiplied  indefinitely.  I 
scarcely  believe  there  is  any  other  domain  of  science  like 
surgery  in  which  Lamarck's  law  of  adaptability  em- 
braced by  Darwin's  doctrine  could  be  better  studied.  For 
in  most  of  our  operations  we  must  expect  this  adapta- 
bility in  a  rational  sense,  otherwise  our  art  would,  indeed, 
be  in  a  bad  plight. 

Naturally,  like  everything  else,  the  rational  way  in 
which  the  body  heals  its  infirmities  has  its  limita- 
tions. Once  these  are  found  in  the  high  and  compli- 
cated organization  of  the  human  body.  No  one  expects 
that  an  amputated  limb  grow  again,  as  in  salamanders, 
and  on  that  account  reproach  nature  with  lack  of  pur- 
posiveness  and  retrogression  in  the  development  of  the 
higher  organized  beings. 

Then  again  we  know  that  the  individual  beings  of  a 
species  vary  in  regard  to  the  good  and  the  bad  side  and 
that  part  of  humanity,  which  when  taken  sick  and  left 
alone  succumb  to  the  disease,  belong  to  the  latter  kind 
of  variation.  For  the  very  disease  is  frequently  possible 
only  because  of  a  giving  way  or  deficient  development  of 
the  natural  defensive  agents,  and  death  from  the  disease 
proves  that  these  agents  which  should  be  at  the  disposal 
of  the  body  are  either  insufficient  or  absent.  Just  in 
these  cases  the  activity  of  the  experienced  physician  has 
to  come  into  play,  for  frequently  it  is  in  his  power  to 
strengthen  and  improve  the  deficient  natural  means  of 


16  INTRODUCTORY 

defense.  Since  time  immemorial  he  has  "been  hailed  as 
the  true  physician,  who  has  learned  from  nature  her 
secrets  in  the  healing  of  disease,  who  supports  her  when 
she  is  unable  to  reach  the  goal  by  her  own«efforts,  who 
replaces  her  when  she  becomes  totally  incapacitated  and 
who  controls  her  when  her  measures  become  excessive 
in  their  action. 

Thus  things  are  theoretically.  But  theory  and  practice 
do  not  always  agree .  and  nowhere  can  this  be  easier 
proven  than  in  our  own  profession.  Certainly  the  cough, 
in  the  sense  I  have  mentioned  above,  is  a  very  useful 
institution  of  defense,  yet,  it  can  so  far  overreach  the 
mark  and  appear  in  the  wrong  place  as  to  represent  in 
reality  the  real  evil  seriously  injuring  the  patient.  In  the 
same  way,  as  explained  above,  we  have  become  con- 
vinced that  while  inflammation  per  se  is  a  useful  process, 
we  are,  nevertheless,  frequently  compelled  to  combat 
all  or  several  of  the  phenomena  to  which  we  apply  the 
collective  name  inflammation,  and  experience  with 
thousands  of  cases  proves  that  this  frequently  is  very 
useful. 

Exactly  the  same  holds  good  in  regard  to  fever. 

Nothing,  therefore,  can  be  more  foolish  than  to 
attempt  to  imitate  the  processes  of  nature  empirically 
and  without  reasoning  in  the  treatment  of  disease,  since 
we  must  never  forget  that  frequently  the  nature  of  even 
the  best  organized  being  is  imperfect  and  that  art  often 
is  far  more  effective  than  nature.  An  excellent  proof  for 
this  is  found  in  the  repair  of  wounds.  The  physician 
cures  by  means  of  the  suture  a  deep  wound,  even  a  yard 
long,  in  eight  to  ten  days  without  any  essential  danger  to 
the  injured  and  re-establishes  the  efficiency  of  the  severed 
tissues  in  the  most  perfect  manner.  This  nature  can 
never  do,  requiring  at  least  months  for  it  and  frequently 
producing  an  imperfect  restoration  of  the  injured  tissues, 
while  the  patient  during  the  time  of  healing  is  exposed 
to  great  dangers  and  inconveniences. 

Nature,  therefore,  in  larger  wounds  does  not  know 
ideal  wound-healing  for  the  simple  reason  that  the  several 
elastic  tissues  separate  and  the  main  condition  for  heal- 
ing by  first  intention — the  apposition  of  the  wound  sur- 
faces— is  absent. 


INTRODUCTORY  17 

Certainly  our  old  masters  were  right  when  they  con- 
sidered the  suppuration  of  wounds  as  something  useful, 
for  this  reason  they  spoke  of  pus  boninn  ct  laudabile.  Art 
had  not  yet  taught  them  to  keep  infection  out  of  their 
wounds;  for  their  soiled  wounds  suppuration  was-  the 
natural  and  useful  reaction,  for  our  wounds  it  is  an  unde- 
sirable addition. 

\Yeuk  minds,  therefore,  while  imitating  the  natural 
processes  in  the  treatment  of  diseases  could  certainly 
produce  the  greatest  mischief,  as  they  would  in  any  other 
occupation.  The  physician  who  has  nothing  else  to  offer 
against  all  diseases  save  a  drug,  the  surgeon  who  knows 
no  other  curative  agent  than  the  knife,  is  just  as  danger- 
ous, and  I  leave  it  to  the  reader  to  decide  who  is  the 
greater  quack,  the  naturopathic  ignoramus,  the  prescrip- 
tion writer  or  the  scalpel  hero. 

Still  all  this  proves  nothing  against  the  general  funda- 
mental principle  of  the  purposiveness  of  the  natural  heal- 
ing processes  and  against  our  duty  to  imitate  them  at 
least  then,  when  in  injuries  of  the  body  they  again  and 
again  reoccur  with  the  certainty  and  regularity  of  a  natu- 
ral law.  In  this  sense,  I  am  sure,  the  physician  is  not 
only  justified  in  but  obliged  to  acknowledge  himself  a 
teleologist.  In  doing  so  we  do  not  represent  a  transcen- 
dental standpoint  but  calculate  with  a  simple  fact  from 
experience.  Experience  has  taught  us  that  on  the  whole 
the  .phenomena  of  life  are  purposive.  We  know  that 
many  of  the  so-called  disease-symptoms  are  bodily  phe- 
nomena of  life  and  we  also  know  that  some  of  the  sym- 
toms  which  we  have  classified  as  belonging  to  the  injury 
in  reality  represent  means  of  defense  against  it.  It  is 
therefore  but  logical  that' we  consider  all  so-called  reac- 
tions of  the  body — and  I  do  not  intend  to  maintain  that 
they  are  all  useful — from  this  point  of  view  in  order  to 
make  practical  use  of  them  when  we  have  recognized 
them  as  useful  agents  of  defense. 

And  why  should  this  teleological  standpoint  be  unscien- 
tific? Perhaps  because  we  can  not  explain  it  exactly. 
AYhere  would  we  land  if,  in  our  craft,  we  demanded 
explanations  for  all  matters  of  facts?  Even  the  most 
exact  among  our  biologists  base  on  equal  matters  of 
fact ;  we  all  make  use  of  the  now  popular  Darwinistic 


18  INTRODUCTORY 

terms,  known  to  every  layman,  such  as  variation,  hered- 
ity, adaptability.  No  one  doubts  that  these  things  are 
effective  in  nature,  but  no  one  has  explained  them ;  they 
are  purely  facts  of  every-day  experience. 

To  many  this  introduction  to  the  following  discussions 
may  appear  somewhat  far-fetched,  but  I  consider  it  as 
very  useful,  for  I  will  frequently  have  to  come  back  to 
these  thoughts  in  the  course  of  this  work,  and  former 
experiences  have  taught  me  that  one  must  be  extremely 
careful  in  the  expression  of  teleologic  views  if  one  does 
not  want  to  give  offense.  Was  I  not  decried  in  a  part  of 
the  literature  as  a  mysticist  and  vitalist  because  of  these 
views  expressed  some  years  ago  in  a  contribution  on  the 
collateral  circulation !  Many  physicians  become  nervous 
when  one  at  all  discusses  phenomena  of  life  and  their  pur- 
posiveness,  §ven  though  it  be  previously  explained  that 
under  such  phenomena  of  life  are  meant  physical  and 
chemical  processes  heretofore  not  at  all  understood,  while 
the  crudest  and  most  improbable  mechanical  explanation 
is  good  enough  for  them.  It  is,  for  instance,  so  unusually 
easy  to  conceive  the  blood  circulation  as  a  water  conduit, 
thus  conveniently  gaining  a  threadbare  scientific  cover 
for  all  possible  things,  but  alas  this  is  false.  And  so 
many  physicians  when  they  have  to  discuss  the  purpos- 
iveness  of  the  phenomena  of  reaction  of  the  body  are 
afraid  to  openly  admit  this.  In  their  discussions  they  put 
the  word  purposiveness  in  quotation  marks  or  believe 
themselves  obliged  to  apologize  for  this  admission  in 
order  to  save  their  standing  as  scientists.  Others 
acknowledge  it  but  ascribe  to  it  only  the  value  of  a 
"heuristic  hypothesis." 

I  have  already  said  that  this  is  retrogression.  For  in 
scientific  biology  the  question  whether  the  organisms  and 
their  life  phenomena  are  purposive  is  not  at  all  discussed, 
this  being  accepted  as  a  self-evident  fact.  Any  discussion 
whatever  is  limited  to  the  question  how  this  purposive- 
ness  of  the  living  beings  as  established  by  experience 
should  be  explained.  The  Darwinists  do  this  by  selection 
in  the  sense  of  the  dictum  frequently  used  by  them : 
"Purposiveness  is  ability  of  existence."  The  vitalists 
have  disputed  that  this  explanation  suffices  and  ascribe 
the  rational  forms  and  arrangement  of  the  organisms  to 


INTRODUCTORY  19 

an  as  yet  mystic  force,  which,  like  the  old  vitalists,  they 
either  call  Power  of  Life  or  like  our  neovitalists  choose 
some  other  paraphrase. 

I  believe  that  at  present  Darwin's  teaching  still  offers 
the  best  explanation  in  relation  to  the  etiology,  prophy- 
laxis and  cure  of  disease :  All  men  provided  with  good 
protective  and  defensive  agents  avoid  or  conquer  the 
diseases  to  which  those  less  favored  in  this  direction 
succumb.  Each  variation  in  the  direction  of  improvement 
of  these  protective  agents  means  a  great  preference  of  the 
individuals  for  they  have  the  prospect  to  live  longer  and 
to  procreate  their  species.  Each  variation  in  the  direc- 
tion of  deterioration  on  the  other  hand,  with  the  great 
spreading  of  opportunities  for  the  acquisition  of  diseases, 
leads  to  a  quick  extermination  of  those  capable  of  less 
resistance.  The  continued  selection  permits  the  species 
to  finally  inherit  the  purposive  qualities  as  a  safe  posses- 
sion. 


A.     GENERAL   PART 


CHAPTER  I 

IN  ALL  IMPORTANT  LIFE  PHENOMENA 
HYPEREMIA  IS  PRESENT 

Every  organ  that  functionates  is  hyperemic  during  its 
activity.  During  every  form  of  growth  and  regeneration 
local  hyperemia  is  present  and  this  in  a  degree  corre- 
sponding to  the  rapidity  and  energy  of  the  growth.  The 
formation  of  antlers  in  the  deer  and  the  moulting  in  birds 
offer  the  best  examples  for  this. 

Generation  and  procreation  are  accompanied  by  the 
most  pronounced  hyperemia — that  of  rut  and  later  preg- 
nancy. 

No  reaction  to  foreign  substances  of  any  kind  occurs 
without  hyperemia,  be  that  substance  a  crude  foreign 
body  or  a  minute  bacterium  not  demonstrable  even  with 
our  most  powerful  magnifying  apparatus,  a  strong  chem- 
ical poison  or  a  lifeless  part  of  our  own  body  (e.  g.,  blood 
effused  into  the  tissues).  Therefore,  I  believe  I  may 
assert:  There  is  no  lesion  which  the  body  tries  to  and  is 
capable  of  removing  or  rendering  harmless,  that  produces 
anemia ;  it  is  always  accompanied  or  surrounded  by 
hyperemia.  If  we,  therefore,  accept  the  reactions  of  the 
body  as  useful  efforts  of  nature,  we  must  admit  that 
hyperemia  is  the  most  widespread  of  all  auto-curative 
agents. 

The  idea  that  the  blood  and  "juices"  heal  diseases  and 
that  "bad  blood  and  bad  juices"  are  aiding  the  develop- 
ment and  spread  of  diseases  is  deeply  rooted  in  the  minds 
of  the  people.  But  scientific  medicine,  too,  has  formed 
the  conception  that  the  quantity  of  blood  of  a  part  of  the 
body  is  of  the  utmost  importance  for  its  well-being.  I 
intend  to  show  in  the  following  pages  that  it  has  pro- 

21 


22          IN  ALL  IMPORTANT  LIFE  HYPEREMIA  IS  PRESENT 

ceeded  one-sidedly.  It  speaks  of  improvement  of  the 
circulation,  removal  of  obnoxious  blood-stasis,  improve- 
ment in  the  nutrition  of  the  parts  by  an  increased  blood- 
current  and  acts  accordingly.  If  we,  however,  observe 
how  nature  works  we  learn  that  while  it  produces  in  all 
important  processes  of  the  body  a  local  hyperemia  in  the 
parts  concerned,  the  same  is  produced  as  frequently  by 
a  slowing  as  by  an  acceleration  of  the  blood-current. 

We  will  later  demonstrate  that  the  latter  occurs  in  the 
functional  hyperemia  accompanying  the  activity  of  the 
organs,  while  the  former  prevails  when  we  have  to  deal 
with  the  removal  of  obnoxious  influences  and  regenera- 
tion of  new  tissue. 

If  we,  therefore,  wish  to  support  the  healing  activity  of 
the  body  by  increasing  the  useful  hyperemia,  we  must,  if 
we  desire  to  imitate  the  processes  of  nature,  in  certain 
cases  increase  the  blood-current  and  diminish  it  in 
others.  If  we  act  differently  we  run  the  risk  of  not  only 
doing  no  good  but  harm  by  disturbing  rational  curative 
processes.  We  will,  therefore,  have  to  study  the  action  of 
the  body  in  each  disease  and  utilize  it  as  a  guide  for  our 
intervention.  For  while  in  many  cases  the  various  forms 
of  hyperemia  have  the  same  effect,  in  others  hyperemia 
and  hyperemia  are  totally  different  things. 

Differences  of  the  utmost  importance,  physically  as 
well  as  chemically,  exist  between  the  rapidly  flowing 
stream  of  arterial  blood  and  the  sluggish  one  of  more 
venous  blood.  Although  our  knowledge  of  the  blood  is 
as  yet  very  limited,  we  know  that  the  former  is  rich  in 
oxygen,  poor  in  carbonic  acid  and  free  alkali,  presenting 
a  comparatively  mobile  fluid,  the  latter,  chemically,  has 
just  the  opposite  characteristics  and  is  a  tenacious, 
sticky  fluid.  We  further  know  that  the  rapidly  flowing 
blood  retains  its  liquidity  and  component  parts  which 
it  carries  along,  while  the  slowly  gliding  blood  sends 
them  out  into  the  tissues,  where  they  can  unfold  their 
activity. 

We  must,  therefore,  always  bear  in  mind  that  the  pro- 
duction of  various  forms  of  hyperemia  represents  a  col- 
lective conception  of  many  physical  and  chemical 
changes. 

It  must  be  added  that  the  various  forms- of  hjperemia 


IN  ALL  IMPORTANT  LIFE  HYPEREMIA  IS  PRESENT          23 

can  not  be  strictly  differentiated,  as  they  pass  unnotice- 
ably  from  one  into  another,  particularly,  as  we  will  yet 
see,  since  the  body  knows  how  to  transform  an  originally 
rapidly  flowing  blood-stream  into  a  slow  one,  by  means  of 
certain  stimuli,  the  nature  of  which  is  unknown,  but 
especially  so  by  irritation  through  inflammation.  Never- 
theless, I  prefer  to  adhere  to  the  conception  of  hyperemia 
rather  than  attributte  the  useful  and  curative  properties 
to  certain  single  components  of  the  blood,  which  is  alto- 
gether based  on  theories  not  proven. 


CHAPTER   II 

ARTIFICIAL  PRODUCTION  OF  HYPEREMIA 

More  than  eleven  years  ago  I  began  to  intentionally 
subject  lesions  to  hyperemia  in  order  to  cure  them  and 
have  widened  my  experiments,  which  at  first  were  limited 
to  tuberculosis.  I  have  gained  a  wide  experience  in 
regard  to  the  effect  of  hyperemia  on  physiological  and 
pathological  processes,  which  I  present  in  this  work. 

.When  I  speak  of  hyperemia  in  the  following  discus- 
sions, I  mean  local  hyperemia  only.  To  avoid  confusion 
I  mention  that,  following  the  usage  of  the  language,  I  call 
a  part  of  the  body  actively  hyperemic  when  its  vascular 
net  is  flooded  by  a  larger  quantity  of  blood,  while  more 
blood  flows  in ;  passively  hyperemic  when  its  vascular 
net  becomes  more  full  on  account  of  a  diminished  venous 
outflow  (stasis  hyperemia).  On  the  whole  it  can  be  said 
that  active  is  equal  to  arterial,  passive  to  venous  hyper- 
emia. But  even  here  we  have  exceptions.  In  heart 
troubles  we  have  passive  hyperemia  of  the  lungs,  yet  it 
is  arterial  (in  consideration  of  the  kind  of  blood  : 'arterial— 
rich  in  oxygen  and  poor  in  carbonic  acid),  for  the  respira- 
tion brings  oxygen  to  the  blood  dammed  in  the  capillaries 
of  the  lungs  and  takes  away  carbonic  acid.  In  such  cases 
a  venous  hyperemia  can  be  conceived  only  when  lack  of 
compensation  is  so  pronounced  that  life  is  in  great 
danger.  This  my  conception  of  the  arterial  hyperemia 
of  lung  stasis  has  been  disputed  in  many  quarters.  I 
regret  that  it  is  impossible  for  me  to  accept  the  objec- 
tions. In  my  opinion,  lack  of  reflection  only  makes  possi- 
ble the  conception  of  a  venous  hyperemia  in  lung  stasis. 
Even  in  pronounced  disturbances  of  compensation  the 
blood  in  the  capillaries  of  the  lungs  is  more  arterial  than 
in  the  capillaries  of  any  other  place  in  the  large  blood 
cycle. 

But  these  are  thoughts  which  are  only  to  be  considered 
when  we  discuss  an  explanation  of  the  effect  of  one  or 
the  other  kind  of  blood.  Where  we  aim  at  practical  ends 
we  can  generally  place  active  for  arterial  and  passive  for 
venous  hyperemia,  a  liberty  we  will  take  advantage  of 
in  the  course  of  this  work. 

24 


CHAPTER   III 

PRODUCTION  OF  ACTIVE  HYPEREMIA 

Active  hyperemia  can  be  produced  in  very  different 
ways.  As  is  well  known  physiologists  make  extensive 
use  of  division  of  vaso-dilating  nerves  (especially  sym- 
paticus  division).  Strictly  speaking  these  experiments 
are  not  pure,  for  the  division  of  the  nerves  produces 
besides  the  hyperemia  a  good  many  injuries,  probably 
more  than  we  realize  for  much  can  escape  our  critical 
investigation.  But  all  aside,  this  kind  of  hyperemia  can 
naturally  not  be  considered  for  therapeutic  purposes. 

Von  Esmarch's  artificial  anemia  develops  very  pro- 
nounced hyperemia — the  so-called  reaction  hyperemia — 
like  after  any  temporary  cessation  or  even  decided  slow- 
ing of  the  blood-current  (10).  But  it  also  can  not  be 
used  for  our  purpose,  for,  first  of  all,  the  method  is  too" 
painful  and  then  the  hyperemia  thus  produced  lasts  only 
a  short  time,  which  leaves  it  out  of  the  question  as  an 
agent  for  the  treatment  of  such  diseases  which  can  be 
influenced  by  hyperemia. 

Increased  activity  of  bodily  parts,  especially  of  the 
muscles,  friction,  massage  and  electricity  produce  decided 
active  hyperemia.  A  good  deal  of  the  efficacy  of  these 
effective  therapeutic  agents  is  probably  due  to  the  pro- 
duction of  hyperemia. 

We  have  at  our  disposal  a  large  number  of  chemicals — • 
all  the  rubefacientia — with  which  to  produce  hyperemia. 
On  the  first  glance  at  the  reddened  area  no  doubt  seems 
left  that  we  have  to  deal  with  an  arterial  hyperemia,  in 
accordance  with  the  old  medical  rule :  Ubi  stimulus  ibi 
ciMu'xus,  still  this  does  not  appear,  to  me  as  proven.  All 
these  remedies  produce  inflammation,  and  we  know  that 
in  this,  after  a  transient  acceleration,  occurs  a  slowing  of 
the  blood-current.  I  will  come  back  to  this  point  later  on 
more  fully. 

For  practical  purposes,  the  most  useful  agent  for  the 
production  of  local  active  hyperemia  is  warmth.  It  has 
been  employed  in  medicine  for  thousands  of  years  with- 
out realization  of  the  fact  that  the  active  hyperemia  pro- 
duced by  it  is  the  most  prominent,  if  not  the  only  curative 

25 


26         PRODUCTION  OF  ACTIVE  HYPEREMIA 

property.  The  body  protects  itself  against  excessively 
high  degrees  of  heat  by  two  means :  first,  by  vigorous 
evaporation  of  sweat  and,  second,  by  a  voluminous  flood- 
ing of  the  heated  part  with  rapidly  flowing  arterial  blood. 
The  latter,  therefore,  acts  like  a  cooling  current.  It 
is  principally  this  accelerated  blood-current  which  we 
very  much  desire,  for,  in  my  opinion,  it  is  the  real  cura- 
tive agent  in  most  of  the  diseases  which  are  favorably 
influenced  by  heat. 

Warmth  can  be  applied  to  the  diseased  part  in  many 
ways,  e.  g.,  hot  compresses  of  linseed,  moor,  mud,  radiat- 
ing heat,  hot  sand  in  the  form  of  specially  constructed 
thermophors,  and  finally  hot  air. 

The  highest  degrees  of  heat  can  be  borne  only  when  the 
last  named  is  employed,  for  the  simple  and  natural  reason 
that  air  is  a  very  poor  conductor  of  heat,  possesses  a 
very  limited  capacity  of  heat  and  the  vigorous  evapora- 
tion of  sweat  protects  the  subjected  parts  against  burns. 
Thus  far  the  matter  is  very  plain  and  in  the  manner  of 
laymen  it  is  astonishing  that  so  high  degrees  of  heat  as 
we  are  able  to  apply  to  the  human  body  without  injury, 
are  borne.  On  the  other  hand,  it  is  less  plain  how  the 
hot  air  produces  a  more  decided  arterial  hyperemia, 
which  is  evidenced  by  the  intensely  and  equally  bright 
reddened  limb  and  the  greater  curative  effect  than  the 
other  named  remedies.  (I  do  not  include  among  them 
radiation  with  electric  light,  because  I  have  no  experience 
with  it.)  If  the  arterial  hyperemia  really  is  the  natural 
protective  and  reactive  process  against  the  obnoxious 
effect  of  high  degrees  of  heat,  as  I  accept  it,  one  would 
conclude  that  any  form  of  heat,  provided  it  be  applied  as 
high  as  the  limit  of  toleration  permits,  would  produce  an 
equally  vigorous  hyperemia. 

But  it  must  not  be  forgotten  that  the  human  body,  with 
all  its  so-called  reactionary  processes,  in  the  first  place  is 
arranged  and  exercised  according  to  the  natural  rela- 
tions by  which  it  is  surrounded.  Now  our  body  must 
continually  adapt  itself  to  the  widest  variations  of  tem- 
perature of  the  air,  while  it  is  but  rarely  exposed  to  the 
variations  of  heat  of  other  substances  with  which  it 
comes  in  contact.  If  it  be  packed  with  heavy,  hot  sub- 
stances (moor,  linseed  poultice,  thermophors),  the  pres- 


PRODUCTION  OF  ACTIVE  HYPEREMIA         27 

sure  on  the  smaller  vessels  might  impede  the  celerity  of 
the  blood-current.  I  suspect  that  hot  water  does  not  pro- 
duce a  purely  active  hyperemia  but  that  it  belongs  to  the 
remedies  producing  slight  inflammation,  which  puts  the 
small  vessels  and  their  contents  in  a  condition  entirely 
unknown  to  us,  that  in  spite  of  dilatation  of  the  small 
vessels  does  not  produce  an  acceleration  of  the  blood- 
current  or  at  least  not  as  much  as  we  would  anticipate 
according  to  known  physical  laws.  The  following  simple 
experiment  shows  that  though  hot  water,  as  w«ll  as  hot 
air,  produces  intense  hyperemia  the  results  are  different : 
I  place  my  right  forearm  in  hottest  possible  air  (105°  C.) 
and  my  left  forearm  in  hottest  possible  water  (44^4°  C), 
leave  them  there  an  equal  time,  and  place  both  limbs, 
after  their  removal,  alongside  each  other.  The  red  left 
forearm  shows  a  bluish  shade,  the  right  is  much  brighter 
and  has  a  yellowish  tinge.  The  difference  is  so  plain  that 
every  observer  can  recognize  it  at  once.  For  the  rest,  the 
hyperemia  visible  on  the  skin  appears  rather  more  intense 
on  the  hand  taken  from  the  hot  water  than  that  from  the 
hot  air.  The  latter,  therefore,  evidently  produces  a 
greater  acceleration  of  the  blood-current  and  for  this 
reason  gives  to  the  limb  the  higher  arterial  color.  It  is 
probable  that  the  swelling  of  the  skin  by  the  water  pre- 
sents a  chemical  change  of  the  tissues  and  thus  a  slight 
inflammatory  circle,  for  which  reason  I  have  frequently 
substituted  hot  physiological  salt  solution  but  without 
causing  any  change. 

But  after  all,  these  are  theoretical  views  and  we  are 
here,  as  everywhere,  left  to  our  practical  experience.  This 
seems  to  prove  to  me  that  among  all  thermic  agents  hot 
air  is  by  far  the  most  useful  and  that  it  produces  the  most 
intense  active  hyperemia.  Next  to  it  in  effect  the  hot 
sand-bath  might  be  counted.  As  my  experience  with 
active  hyperemia  is  almost  exclusively  limited  to  that 
produced  by  hot  air  and  as  this  method  of  applying  heat 
is  universally  the  most  practical  and  effective  I  will  essen- 
tially confine  myself  to  it. 

Hot  air,  of  late,  has  been  made  extensive  use  of  for 
therapeutic  purposes.  That  the  hyperemia  produced  by 
it  is  the  essential  thing,  has  until  recently  been  neglected, 
nay,  even  denied,  and  this  is  sometimes  done  even  now. 


28         PRODUCTION  OF  ACTIVE  HYPEREMIA 

Thus  at  the  fifteenth  congress  of  internal  medicine,  in  the 
exhaustive  discussions  on  the  treatment  of  chronic  rheu- 
matism not  a  word  was  said  in  regard  to  it  being  the 
hyperemia  which  was  effective  in  the  recommended  treat- 
ment by  heat,  though  I  had  emphasized  that  long  ago. 
A  year  later  at  the  same  congress,  Tallerman's  hot-air 
apparatus  was  exhibited  and  though  Mendelssohn  dis- 
cussed it  at  great  length,  my  explanation  of  the  effect 
of  hot-air  therapy  was  not  mentioned  by  the  lecturer, 
yet  in  the  previous  year  I  had  again  called  attention  to  it. 
During  the  discussion  Baumler  was  the  only  one  who 
briefly  mentioned  my  explanation  at  this  congress. 

Since  ages  the  external  application  of  warmth  has  been 
counted  in  medicine  among  the  agents  which  lead  blood 
from  the  depth  to  the  surface.  Observing  the  pronounced 
reddening  of  the  skin  after  its  use,  it  was  concluded  that 
the  dilatation  of  the  superficially  situated  vessels  "decon- 
gestionated,"  as  it  was  termed,  the  deeper  parts  over- 
filled with  blood.  Francois  Franck  (12),  in  a  much-talked- 
of  work  on  "Revulsion,"  has  attempted  to  give  this  opin- 
ion a  scientific  basis  and  hydrotherapy — in  the  widest 
sense — which  is  prominently  concerned  with  the  appli- 
cation of  stimuli  by  cold  and  warmth,  has  unreservedly 
appropriated  his  view  and  transferred  his  views  to  the 
stimuli  of  temperature,  although  Franck  talks  only  of 
"stimulating  inunctions,  sinapisms,  cupping  glasses,  igni- 
puncture  and  vesicantia." 

Franck  demonstrated  that  skin  stimulation  was  fol- 
lowed by  contraction  of  the  vessels  of  the  viscera  and 
by  dilatation  of  those  of  the  superficial  parts  and  that  by 
reflex.  Irritation  of  the  skin  is  said  to  produce  a  stimulus 
of  the  vaso-constrictor  nerves  of  the  former  and  at  the 
same  time  of  the  vasodilator  of  the  latter.  ,  In  this  man- 
ner, according  to  Franck,  are  explained  the  effects  of 
revulsion.  They  have  "decongestionating"  influence  and 
draw  the  blood  which  stagnates"  in  diseased  viscera 
towards  the  surface.  He  thus  gave  the  apparently  indis- 
putable scientific  explanation  not  only  for  the  effect  of 
numerous  chemical  skin-irritants  which  have  been  in  use 
since  very  ancient  ages,  but  also  of  the  many  forms  of 
thermic  influences,  which  should  be  effective  in  deep 
parts. 


PRODUCTION   OF  ACTIVE   HYPEREMIA  29 

This  explanation*interests  us  here  very  little,  as  we 
have  but  little  to  do  with  such  extensive  distance  effects 
(from  the  skin  into  the  depth  of  the  viscera).  On  the 
first  glance  it  appears  very  evident,  for,  as  we  have  long 
known  from  physiology',  an  extensive  hyperemia  of  the 
external  parts  is  possible  only  when  the  viscera  give  the. 
blood  for  it  and  vice  versa.  But  Franck's  experiments 
are  by  no  means  convincing.  For  the  purpose  of  measur- 
ing the  variations  in  the  volume  of  blood  he  has  placed  the 
kidney  in  a  volumetric  apparatus.  But  if  the  abdominal 
viscera  are  exposed  their  vessels  change  from  the  nor- 
mal, as  I  can  assure  from  a  wide  personal  experience  and 
as  is  evident  from  other  examinations  (13),  and  one  is  led 
to  erroneous  views.  And  how  much  more  must  this  be  the 
case  when  a  whole  kidney  in  connection  with  its  vessels 
is  placed  in  an  apparatus.  For  this  reason  it  appears  to 
me  very  bold  to  draw  such  far-reaching  conclusions  from 
such  crude  experiments,  which  have  no  bearing  to  the 
natural  relations. 

Let  us,  nevertheless,  accept  as  correct  this  effect  in  rela- 
tion to  skin  and  viscera,  which  is  also  treated  in  older 
physiological  works.  It  is  hazardous  and  entirely  false 
to  apply*  these  views  to  parts  which  are  situated  close  to 
each  other.  Thus  Franck's  experiments  have  been  cited 
as  proof  for  the  old  view  that  reddening  of  the  skin  of  a 
limb  frees  the  deeper  parts,  e.  g.,  muscles  and  joints,  from 
an  obnoxious  hyperemia.  This  is  a  fundamental  mistake 
which  has  given  cause  to  the  wrongest  possible  views. 
The  agents  known  as  rubefacientia  act  into  deep  parts  by 
producing  hyperemia,  and  this  we  will  discuss  in  detail 
in  a  subsequent  chapter.  I  have,  therefore,  always  taken 
the  view  that  the  hyperemia  produced  by  heat  is  not 
limited  to  the  skin  depleting  the  deeper  parts  but,  on  the 
contrary,  occupies  the  entire  thickness  of  a  limb  which 
has  been  exposed,  provided  the  heat  was  intense  enough. 
My  assistant,  Dr.  Klapp,  (14)  has  even  proven  that  it 
continues  from  the  surface  to  the  viscera :  he  put  the 
abdomen  of  a  rabbit  in  a  hot-air  apparatus,  exposed  it 
for  some  time  to  intense  heat,  opened  its  abdominal  cavity 
immediately  on  removal  of  the  animal  from  the  apparatus 
and  regularly  found  a  hyperemia  of  the  entire  abdominal 


30         PRODUCTION  OF  ACTIVE  HYPEREMIA 

> 

wall,  tne  serosa  of  the  intestines  and  of  the  centrum 
tendineum  of  the  diaphragm. 

Plethysmographic  examinations  prove  that  warmth 
enlarges  the  contents  of  limbs  encased  in  the  apparatus 
and  that  cold  diminishes  it  (15).  Evidently  these  differ- 
ences are  but  due  to  the  changing  volume  of  blood.  Un- 
fortunately these  experiments  offer  no  explanation 
whether  the  hyperemia  which  swells  the  heated  limbs  is 
limited  only  to  the  superficial  parts  or  whether  it  also 
spreads  into  the  depth.  '  Thus  Sarah  Amitin  thinks  it 
possible  that  in  spite  of  the  increase  in  volume  produced 
by  the  warmth  this  agent  may  deplete  the  deeper  vessels. 

The  most  important  and  decisive  proof  that  heat  favor- 
ably influences  diseased  deep  parts  by  hyperemia  and  not 
by  the  so-called  "decongestion,"  is  the  fact,  discovered 
by  me  and  which  I  will  more  fully  dwell  on  in  this  work, 
that  on  the  contrary  a  stasis  hyperemia,  the  removal  of 
which  was  considered  essential,  repeatedly  shows  the 
same  effect  as  the  heat,  which  is  believed  to  be  a  derivans 
or  revulsive  agent.  In  this,  therefore,  utterly  false  con- 
ceptions have  been  entertained. 

The  hydrotherapists  think  that  thermic  stimuli  in- 
fluence the  distribution  of  blood  by  reflex.  I  have  already 
mentioned  the  experiments  by  Frangois  Franck.  They 
also  call  attention  to  the  certainly  interesting  experi- 
ments by -Brown,  Sequard,  Schiiller,  Samuel,  Winternitz 
and  others.  They  have  even  asserted  that  they  are  able 
to  influence  certain  internal  bodily  parts  from  certain 
places  on  the  skin.  Leichtenstern,  in  his  Balneotherapy, 
and  Matthes,  in  his  text-book  of  clinical  hydrotherapy, 
have  sharply  opposed  partly  the  correctness  of  the  experi- 
ments, partly  the  justification  to  make  use  of  them  for 
practical  purposes.  And,  indeed,  anyone  who  has  per- 
formed similar  physiological  experiments  like  those  under 
consideration  will  assent  that  Matthes  is  right  when  he 
denies  the  large  majority  of  these  experiments  any  value 
of  proof.  In  this  domain  prevails  a  great  deal  of  arbitrari- 
ness in  the  establishment  and  .interpretation  of  physio- 
logical experiments.  We  will  occupy  ourselves  with  these 
only  so  far  as  they  here  interest  us,  viz.,  that  the  phenom- 
ena produced  by  hot  air  on  such  bodily  parts  as  have  been 
exposed  to  it  have  been  placed  under  the  category  men- 


PRODUCTION  OF  ACTIVE  HYPEREMIA         31 

tioned  above.  Whether  really  in  hyperemia  produced  by 
hot  air  the  reflexes  play  any  role  no  one  knows.  But  we 
are  positive  that  hyperemia  in  its  entire  extent  can  be 
produced  without  the  medium  of  the  nervous  system. 
This  is  proven  by  the  following"  experiment:  I  placed  a 
young1  white  pig*  under  deep  ether  narcosis  and  dissected 
the  femoral  artery  and  vein  of.  one  hind  leg  clean  out  of 
its  sheath.  I  then  cut  through  all  other  soft  parts  and 
ligate  all  bleeding  vessels.  The  limb  now  is  connected 
with  the  rest  of  the  body  only  by  the  bone  and  the  two 
main  vessels ;  all  nerves  especially  are  severed.  I  then 
placed  the  limb  in  a  hot-air  apparatus  and  observe  that 
the  hyperemia  appears  exactly  in  the  same  way  as  in  the 
other  normal  limb.  The  hyperemia  disappears  also  just 
as  rapidly,  provided  burns  have  been  avoided.  All  three 
degrees  of  burns  can  be  produced  in  the  dissected  leg. 

Lewaschew  (16)  flooded  amputated  extremities  with 
defibrinated  blood  and  established  that  warmth  produces 
dilatation  and  cold  constriction  of  the  vessels  and  that  the 
rapidity  of  the  outflow  was  influenced  accordingly.  Un- 
fortunately I  can  not  recognize  these  experiments  as 
offering  proof.  I  have-  already  explained  in  an  earlier 
contribution  (17)  that  the  flooding  of  amputated  parts 
of  the  body  with  blood  freed  from  fibrin  under  a  constant 
pressure  leads  to  opposite  results  and  that  these  experi- 
ments for  this  reason  can  not  be  made  use  of. 

Pietrowski  (18)  found  in  plethysmographic  examina- 
tions that  even  parts  of  the  body  from  which  the  nerves 
have  been  removed  have  retained  irritability  of  the  ves- 
sels. The  same  has  been  established  also  by  other  experi- 
menters. 

I  myself  have  demonstrated  that  the  so-called  reaction 
hyperemia,  which  appears  after  artificial  anemia,  is 
entirely  independent  of  the  central  nervous  system  (19). 

Goltz  and  Ewald  (20)  show  magnificently  that  the 
innervation  of  the  vessels  is  independent  of  the  central 
nervous  system.  The  vessels  of  a  dog  from  whom  the 
largest  part  of  the  spinal  cord  has  been  removed  piece- 

*The  pig  is  the  best  animal  for  examinations  of  the  distribution  of  blood.  The 
white  skin  enables  us  to  recognize  any  change  in  the  volume  or  kind  of  blood  with 
ease. 


32  PRODUCTION  OF  ACTIVE   HYPEREMIA 

meal  retain  the  faculty  to  constrict  or  dilate  in  accord- 
ance with  the  nature  of  the  external  stimulus  used. 

It  is  therefore  positive  that  hyperemia  by  heat  can 
occur  solely  through  local  influences  on  the  vessels  with- 
out the  agency  of  the  central  nervous  system  or  the  nerve 
trunks.  Whether  there  exists  an  immediate  stimulation 
of  the  wall  of  the  vessel  or  whether  Goltz  is  right  in 
accepting  vessel  ganglia  (which  so  far  have  not  been  dis- 
covered) remains  to  be  seen. 

Finally  it  is  not  even  undisputed  that  the  heat  produces 
an  active  hyperemia  for  Winternitz  and  his  pupils  con- 
sider it  a  passive  hyperemia.  It  seems  to  me  that  a 
glance  at  the  skin  of  a  white  creature  (man  or  pig)  which, 
for  example,  has  been  exposed  to  intensely  heated  air 
for  some  time,  would  leave  no  doubt  that  there  can  be 
anything  else  but  an  arterial  hyperemia,  for  the  developed 
redness  is  possibly  higher  and  more  vivid  than  that  fol- 
lowing artificial  bloodlessness  and  of  this  we  know  that 
it  is  an  arterial  hyperemia  with  extraordinary  accelera- 
tion of  the  blood-current.  However,  I  have  tried  to  sup- 
port this  view  by  several  experiments:  I  place  the  leg  of 
a  dog  which  is  anesthetized  with  ether  in  a  hot-air  appa- 
ratus for  half  an  hour  and  render  the  extremity  very 
hyperemic.  On  opening  the  previously  dissected  femoral 
vein  blood  flows  from  the  vein  in  lively  pulsations.  This 
is  a  repetition  of  a  well-known  physiological  experiment 
to  demonstrate  the  acceleration  of  the  arterial  blood-cur- 
rent. Tire  bright  red  of  the  venous  blood  as  compared 
with  that  of  the  other  leg  should  be  striking.  In  two 
experiments  I  could  not  establish  this.  In  spite  of  the 
ether  narcosis  the  blood  of  both  veins  was  bright  red. 
P>ut  in  the  leg  which  was  not  rendered  hyperemic  the 
flow  of  the  blood  in  pulsations  was  absent. 

The  following  experiments  will  plainly  show  that  a 
rapid  blood-stream  is  indeed  necessary  for  the  endurance 
of  high  degrees  of  heat,  playing  the  role  of  a  cooling 
stream  for  the  heated  limb. 

I  place  my  arm  in  a  hot-air  apparatus  and  heat  it 
slowly.  When  the  thermometer  shows  114°  C.  I  can  bear 
the  heat  very  well ;  at  H5°C.  a  disagreeable  burningsensa- 
tion  under  the  nails  appears.  The  temperature  between 


PRODUCTION   OF  ACTIVE   HYPEREMIA  33 

114°  and  115°  can  be  borne  for  some  time  without  diffi- 
culty. During  this  the  limb  perspires  moderately. 

Now  the  same  limb,  with  a  rubber  bandage  attached  to 
the  arm,  which  produces  a  moderate  stasis  hyperemia,  is 
placed  in  the  same  apparatus  in  the  same  position,  and 
heated  in  the  same  manner.  At  98°  a  smart  burning 
under  the  nails  appears.  Somewhat  under  this  degree 
the  heat  can  be  comfortably  borne  for  some  time.  Here 
too  the  arm  is  moist  from  perspiration. 

If  I  produce  in  the  same  extremity  a  pronounced  stasis 
hyperemia  so  that  the  radial  pulse  can  be  plainly  felt  and 
place  it  under  the  same  conditions  in  the  hot-air  appa- 
ratus I  have  reached  at  78°  the  limit  of  endurance. 

Inasmuch  as  many  experiences  show  that  a  venously 
hyperemic  limb  shows  rather  an  increased  amount  of 
perspiration  it  can  be  but  the  diminished  current-rapidity 
of  the  blood  which  is  the  cause  of  the  greater  sensitive- 
ness to  the  heat ;  we  have  slowed  the  cooling  current  in 
this  case  which  together  with  the  perspiration  protects 
against  burns. 

To  make  doubly  sure  I  have  also  made  the  counter- 
test  :  I  render  my  arm  bloodless  by  constriction  for 
sixteen  minutes.  On  loosening  the  bandage  appears  the 
enormous  reaction  hyperemia,  fully  known  to  us  surgeons 
as  a  great  acceleration  of  the.  blood-stream.  The  limb  is 
now  placed  under  the  same  conditions  in  the  same  appa- 
ratus as  before,  previously  heated  throughout  to  145°. 
The  limb  bears  this  heat  very  well  and  perspires  freely.  I 
remove  the  arm  from  the  apparatus,  wait  until  it  has 
entirely  paled  and  replace  it  while  the  thermometer  still 
shows  145°.  The  heat  can  now  be  borne  only  for  a  few 
seconds,  then  it  must  be  withdrawn  on  account  of  the 
unbearable  burning  sensation. 

In  this  category  come  also  the  following  observations : 
I  expose  my  pelvis  in  a  hot-air  apparatus  to  a  degree 
of  heat  which  can  just  be  comfortably  borne.  If  I  now 
produce  retro-stasis  by  holding  the  breath  and  forcible 
expiratory  pressure  while  nose  and  mouth  are  closed, 
the  heat  becomes  unbearable ;  the  burning  sensation  dis- 
appears as  soon  as  respiration  is  resumed. 

If  I  make  the  same  experiment  with  my  arm  I  feel  the 

3 


34  PRODUCTION  OF  ACTIVE  HYPEREMIA 

following:  In  the  beginning  of  the  pressure  the  heat  is 
plainly  less  felt,  gradually  this  relief  gives  way  to  a 
sensation  of  burning.  Immediately  after  the  resumption 
of  respiration  appears  a  greatly  increased  sensation  of 
burning  which  again  quickly  disappears. 

All  these  experiments  have  been  tried  by  one  of  my 
assistants  with  like  success. 

That  the  rapid  blood-current  is  a  protective  agent 
against  burns  is  brilliantly  demonstrated  by  the  following 
experiment :  I  place  my  arm,  on  which  a  slight  stasis 
hyperemia  has  been  produced  by  means  of  a  rubber  ban- 
dage, for  one  hour,  in  hot  air  which  can  be  comfortably 
borne.  After  paling  of  the  hyperemic  skin  remains  a 
beautiful  net  of  red  stripes  which  can  be  recognized  with- 
out difficulty  as  corresponding  to  the  network  of  the 
small  superficial  veins  of  the  skin.  The  larger  subcutan- 
eous veins  have  not  marked  their  course.  The  red  stripes 
disappear  after  about  twelve  hours. 

Here  we  have,  therefore,  a  case  of  very  slight  burn 
exactly  in  the  course  of  the  small  veins  of  the  skin,  in 
which  on  account  of  the  insignificant  stasis  the  blood-cur- 
rent has  been  slowed.  A  better  proof  for  the  correctness 
of  my  view  that  the  blood-current  represents  a  cooling 
stream  no  one  will  demand.  I  have  for  this  reason 
abstained  from  difficult  physiological  experiments  the 
results  of  which  may  nevertheless  be  neither  certain  nor 
plain.  Such  experiments  have  been  made  by  Balli  (21) 
with  v.  Kriess'  flame-tachygramm.  He  measured  with  it 
the  rapidity  of  the  blood-current  in  the  human  arm  which 
he  had  placed  in  a  plethysmograph  with  hot  water  of 
variable  temperature.  He  found  that  heat  enlarged,  the 
pulse  of  the  stream  while  cold  lessened  it. 

I  add  that  animals  which  do  not  at  all  visibly  perspire 
but  evaporate  a  little  through  the  skin  and  produce  the 
regulation  of  bodily  heat  by  means  of  the  more  or  less 
accelerated  respiration,  such  as  the  dog,  tolerate  at  least 
the  same  degrees  of  heat  as  does  man,  of  which  I  have 
been  doubtlessly  informed  by  experiments.  I  placed  limbs 
of  dogs  in  the  hot-air  apparatus.  They  remained  dry  but 
were  rendered  hyperemic.  In  earlier  experiments  I  have 
noticed  that  in  dogs  of  a  dark  skin  the  intense  reaction 
hyperemia  after  artificial  bloodlessness  can  not  be  noticed. 


PRODUCTION  OF  ACTIVE  HYPEREMIA         35 

If  I  however  exposed  these  dark-colored  limbs  to  intense 
hot  air  I  could  not  remain  in  doubt  concerning  the  enor- 
mous hyperemia.  This  in  such  animals  is  no  doubt  for 
this  reason  so  developed,  because  the  cooling  blood- 
stream must  replace  the  lacking  perspiration. 

Considerable  curative  effects  have  been  ascribed  to  the 
rich  perspiration  which  follows  the  application  of 
even  local  heat.  For  in  many  of  such  diseases  which,  in 
my  opinion,  are  favorably  influenced  by  the  reaction 
hyperemia  of  heat,  general  sweat-cures  had  been  insti- 
tuted for  ages,  so,  for  example,  in  the  stiffened  joints  of 
chronic  rheumatism,  arthritis  deformans  and  especially 
in  dropsical  effusions  of  the  joints.  In  the  latter  the  idea 
prevailed  that  by  the  dehydration  of  the  entire  body  the 
effusion  could  be  made  to  be  absorbed. 

I  am  not  so  one-sided  as  to  deny  that  perspiration  may 
prove  a  great  role  in  absorptions  in  the  body,  I  even  do 
not  want  to  assert  that  this  could  not  be  useful  in  the 
affections  cited.  But  the  perspiration,  especially  in  the 
affections  which  are  here  of  interest  to  us  and  in  which 
we  make  therapeutic  use  of  purely  local  heat,  certainly 
plays  but  a  secondary  part.  I  have  proven  this  by  im- 
proving with  the  hot-air  apparatus  stiffened  fingers 
singly,  in  the  heating  of  which  there  can  be  no  thought 
of  an  essential  loss  of  sweat.  Therefore  the  general 
employment  of  heat  is  the  agent  that  is  the  most  effec- 
tive. 

AYith  general  hot  sand-baths  a  loss  of  body  weight  up 
to  3  kg.  has  been  reported,  while  Mendelsohn  (22) 
experienced  a  loss  of  only  750  g.  after  subjecting  his  arm 
for  one  and  one-half  hours  to  a  hot-air  bath  of  120°, 
Krause  (23)  observed  on  a  female  patient  on  whom  he 
used  hourly  a  hot-air  apparatus  in  seven  days  270-500  g. 
daily.  Experience,  however,  teaches  that  in  the  above- 
named  diseases  just  this  local  application  of  heat  is  the 
most  effective.  Now  it  is  impossible  to  take  the  view 
that  local  losses  of  sweat  remove  absorbable  obnoxious 
substances  from  its  immediate  vicinity,  in  the  same  sense 
that  the  old  physicians  thought  the  materia  peccans  was 
removed  by  a  derivans. 

The  following  statements  by  Schreiber  (24)  appear  to 
me  as  of  importance  here :  The  secretion  of  sweat  begins 


36  PRODUCTION  OF  ACTIVE  HYPEREMIA 

to  be  stimulated  at  low  degrees  of  heat  (45-50°  C.),  at 
60-70°  it  is  increased  and  at  higher  degrees  it  frequently 
becomes  less  and  occasionally  disappears  at  80-90°,  so 
that  the  skin  feels  smooth  and  dry.  Schreiber  is  of  the 
opinion  that  this  dryness  is  not  only  the  consequence  of 
the  rich  evaporation  but  that  on  account  of  the  over- 
stimulation  and  exhaustion  of  the  nerves  of  the  sweat- 
glands  really  less  sweat  is  excreted.  On  the  other  hand 
he  admits  that  with  increasing  heat  the  hyperemia 
becomes  more  intense  and  that  this  reaches  the  maximum 
at  the  highest  degrees  of  heat.  Schreiber  thinks  that  for 
the  production  of  rich  perspiration  lower  degrees  of  tem- 
perature are  sufficient  and  doubts  the  necessity  of  obtain- 
ing the  most  intense  hyperemia. 

If  I  compare  with  this  my  own  experience,  I  must 
remark  that  to  me,  too,  it  seems  that  the  greatest  amours  i 
of  perspiration  does  not  occur  at  the  highest  degrees  of 
heat;  however,  I  do  not  recollect  to  have  observed  the 
dry  and  shining  reddened  limbs  described  by  Schreiber 
as  following  the  effects  of  high  temperatures.  Now  coin- 
ciding experience  points  to  the  fact  that  in  order  to  obtain 
good  effects  high  .temperatures  are  necessary  and  good 
results  have  been  obtained  with  them  after  lower  degrees 
which  produce  an  equal  amount  of  perspiration  but  not 
as  intense  an  hyperemia  have  failed.  As,  therefore,  of 
both  reaction  processes,  perspiration  and  increased  blood  - 
current,  the  latter  only  has  become  increased  with  the 
higher  temperature  it  only  can  be  held  responsible  for  the 
better  effect.  I,  therefore,  do  not  agree  with  Schreiber 
who  says  that  the  intense  hyperemia  is  not  necessary. 
Certainly  the  heat  must  not  rise  enough  to  cause  burns, 
for  these  probably  would  stop  the  active  hyperemia. 
They  lead  to  inflammatory  conditions  in  the  skin  which 
possibly  are  followed  by  a  slowing  of  the  blood-current. 

The  fact  that  in  chronic  stiffened  joints  such  of  them 
which  have  not  been  exposed  to  heat  have  improved  at 
the  same  time  as  did  those  which  have  been  thus  treated, 
has  been  argued  against  the  hyperemia  as  having  the 
decisive  curative  properties  in  affections  subjected  to 
hot-air  therapy.  At  first  glance  it  would  seem  to  speak 
for' a  general  effect  of  the  locally  applied  heat,  influencing 
the  entire  body.  This  conclusion  is  positively  reached  by 


PRODUCTION   OF   ACTIVE    HYPEREMIA  37 

Walsh  (25),  honorary  medical  officer  to  the  Tallerman 
free  institute  in  London.  Walsh  observed  the  improve- 
ment of  an  old  case  of  chronic  eczema  of  both  hands, 
which  had  defied  all  possible  methods  of  treatment 
although  only  the  right  hand  has  been  treated  with  the 
Tallerman  hot-air  apparatus.  He  even  believed  that  a 
stiff  elbow-joint  could  be  improved  or  cured  from  local 
hot-air  treatment  of  a  leg  and  ascribes  this  to  the  general 
effect  of  the  local  hot-air  bath  which  manifests  itself  in 
perspiration,  rise  of  pulse  and  bodily  temperature.  I 
doubt  very  much  that  this  view  is  correct  and  though  I 
myself,  like  many  others  who  make  use  of  this  method 
of  treatment,  have  seen  that  individual  joints  which 
have  not  been  treated  have  improved,  the  effect  was 
never  as  pronounced  as  in  those  which  have  been  treated 
and  very  frequently  it  was  absent  altogether.  Never- 
theless the  fact  remains  but  it  can  be  explained  more 
naturally  in  a  different  way :  We  know  that  each  decided 
heat-effect  on  external  parts  of  the  body  draws  blood 
from  the  viscera  to  these  parts.  Therefore,  when  we 
have  a  decided  influence  of  hot  air  on  a  part  of  the  body 
all  other  limbs  and  superficially  situated  parts  participate 
in  the  increased  flooding  of  blood.  We  further  know  that 
in  multiple  lesions  if  one  of  them  has  been  removed 
the  others  may  improve.  We  surgeons  know  this  in 
tuberculosis  and  each  of  us  has  seen  how  an  individual 
has  recuperated  against  all  expectation  from  a  grave  case 
of  pulmonary  consumption  after,  for  instance,  the  re- 
moval of  a  leg  on  account  of  advanced  tuberculosis  of  the 
knee-joint.  Thus  I  have  also  observed  that  in  chronically 
stiffened  joints  such  that  were  not  treated  have  improved 
when  I  subjected  the  worst  among  them  to  stasis  hyper- 
emia.  Just  such  an  experience  proves  best  that  we  do  not 
have  here  to  deal  with  a  general  effect  of  locally  applied 
heat  but,  in  one  as  in  the  other  case,  with  effects  of 
hyperemia. 

The  observation  of  Chretien  cited  by  Walsh,  who  has 
seen  in  a  case  of  gout  after  the  treatment  of  a  gouty 
joint  with  hot  air  an  increased  excretion  of  uric  acid  from 
the  kidneys,  does  not  speak,  as  Walsh  thinks,  for  a  dis- 
tance effect  on  these  organs,  but  all  the  more  for  an 


38         PRODUCTION  OF  ACTIVE  HYPEREMIA 

effect  by  hyperemia.  I  will  soon  show  that  active  hyper- 
emia,  produced  by  heat,  has  absorptive  powers  of  a 
high  degree.  Like  all  other  pathological  substances,  the 
hyperemia  will  wash  away  the  urinary  salts  accumulated 
in  the  joints  and  cause  their  excretion  through  the 
kidneys. 

The  decisive  proof  that  really  the  hyperemia  and  not 
the  other  phenomena  which  accompany  the  application  of 
heat,  is  the  effective  agent,  can  again  be  concluded  from 
the  fact  that  all  possible  forms  of  hyperemia  produced 
in  a  different  manner,  which  have  no  general  effects  at 
all,  act  similarly. 

I  must  remark  right  here  that  it  seems  to  me  as  if 
the  influence  of  heat  on  the  entire  body  and  on  single 
parts  has  not  been  sufficiently  separated.  It  is  evidently 
something  entirely  different  when  I  place  an  individual  in 
a  hot-air  or  sand  bath  up  to  the  neck  or  only  an  arm.  In 
the  former  case  an  enormous  amount  of  blood  is  drawn  to 
the  skin  which  naturally  must  be  furnished  from  deeper 
parts,  in  the  latter  we  have  a  sufficient  quantity  of  blood 
to  render  the  limb  hyperemic  throughout  its  entire  thick- 
ness. 


CHAPTER  IV 


(By  the  Editor  ) 

Probably  Professor  Bier  was  the  first  (26)  to  con- 
struct hot-air  apparatus  for  the  treatment  of  local  affec- 
tions by  means  of  arterial  hyperemia.  He  has  made  use 
of  such  apparatus  since  1891.  Clado  (27)  constructed  an 
oven  from  hot  bricks  which,  however,  was  so  clumsy  that 
it  found  no  imitators.  Bier  learned  of  this  later  through 
the  literature.  Clado  put  extremities  afflicted  with  tuber- 
culosis into  the  oven  with  the  view  of  destroying  the 
tubercle  bacilli  by  heat.  The  air  in  the  oven  had  a  tem- 
perature of  130°  C.  and  below  the  layer  of  cotton  110°  C. 
Bier  is  undoubtedly  entitled  to  priority  because  Clado  had 
not  yet  published  an  account  of  his  work  when  he  first 
constructed  and  used  his  apparatus,  which  is  very 
simple  indeed.  In  principle  it  is  patterned  after 
Quincke's  cabinet  for  the  entire  body.  Heat  is  obtained 
from  a  Quincke  chimney  which  has  been  modified  to  per- 
mit the  regulation  of  its  height,  similar  to  the  apparatus 
used  by  chemists.  The  plate  on  which  the  lamp  rests  can 
also  be  raised  or  lowered  at  will.  Bier  prefers  a  Bunsen 
gas  burner  with  a  stop-cock  by  means  of  which  the  heat 
can  be  increased  or  diminished. 

"\Yhere  no  gas  can  be  had  alcohol  is  to  be  used  as  fuel. 
After  experimenting  with  a  variety  of  lamps  Bier  decided 
on  the  simplest  form  of  alcohol  lamp — a  large  container 
with  a  wide  wick.  The  heat  is  regulated  by  raising  or 
lowering  the  wick  or  by  changing  the  position  of  the 
lamp. 

Bier's  hot-air  apparatus  is-  practically  nothing  eise 
than  wooden  boxes  with  openings  for  the  insertion  of  the 
various  limbs  or  parts  of  them.  They  have  on  the  top 
openings  for  a  thermometer  and  for  the  purpose  of  venti- 
lation. The  chimney  carrying  the  heat  into  the  box  is 
attached  to  an  opening  at  the  bottom.  Cuff  attachments 
are  used  when  the  heat  is  carried  to  a  region  which  can 
not  be  placed  in  the  box,  such  as  the  shoulder-joint,  back, 

39 


40 


HOT  AIR  TREATMENT  APPARATUS 


thigh,  etc.  Several  boxes  are  needed  to  suit  certain  single 
joints  and  regions,  though  the  inventor  has  also  devised 
a  "universal"  box.  The  wood  is  rendered  fireproof  by 
saturation  in  chemicals. 

Bier's  hot-air  apparatus  has  been  imitated,  modified 


or  improved  by  several  physicians.  All  these  are  men- 
tioned and  criticized  in  the  original,  but  as  they  are  but 
little  known  and  used,  if  at  all,  in  this  country,  the  editor 
thought  best  to  publish  a  short  resume  only  for  the  sake 
of  completeness. 


HOT  AIR  TREATMENT  APPARATUS 


41 


In  Germany  the  best  known  hot-air  apparatus  is  that 
made  by  Kranse  (28).  Bier  says  it  has  many  shortcom- 
ings. Wilson  (29)  describes  an  "oven"  similar  to  that  of 
Kranse.  As  an  innovation  a  salt  mass  is  placed  in  the 
"oven"  to  absorb  the  sweat  and  thus  to  keep  the  interior 


dry.  Rcitlcr's  (30)  apparatus  is  scarcely  different  from 
Krause's  model.  He  makes  use  of  a  shallow  dish  with 
powdered  dehydrated  calcium  chloride  for  the  absorption 
of  evaporated  sweat.  Roth  (31)  improves  the  Krause 
model  by  the  insertion  of  an  asbestos  cylinder.  He  also 
recommends"  an  apparatus  which  he  calls  "polytherm," 


42 


HOT  AIR  TREATMENT  APPARATUS 


intended  for  the  various  extremities,  but  which  is  similar 
to  Bier's  "universal"  box  (32). 

The  successes  obtained  vrithT oiler  man's  apparatus  are 


Figs.  1  and  2. 

Illustrating  the  Betz  Arm  and  Leg  Hot-Air  Apparatus  as  applied  to 
extremities  and  bodily  parts. 


responsible  for  its  widespread  popularity.  Tallerman's 
apparatus,  however,  did  not  exist  when  Bier  first  pub- 
lished (33)  his  invention  in  January,  1893,  after  having 
used  his  hot-air  boxes  about  two  years.  In  two  addi- 
tional publications  (34)  Bier  proves  this  conclusively. 


HOT   AIR  TREATMENT  APPARATUS 


43 


Tallerman's  apparatus  is  clumsy  and  expensive,  looking 
more  like  steam  kettles.  It  is  heated  by  a  large  number 
of  gas  flames.  Asbestos  lines  the  interior  of  the  appa- 
ratus to  prevent  contact  of  the  extremities  with  the 


Fig.  3. 
Betz'  Knee  Hot-Air  Apparatus. 


heated  walls.  Bier  sees  no  advantage  in  Tallerman's 
apparatus  over  his  or  similarly  constructed  apparatus. 
In  this  the  editor  fully  agrees. 

Mention  is  made  in  the  original  of  Kellogg's  (35)  elec- 


44 


HOT   AIR   TREATMENT   APPARATUS 


trie  light  cabinet,  with  which  undoubtedly  American 
readers  are  more  or  less  familiar.  The  light  per  se  seems 
to  be  the  therapeutic  agent  wanted  by  its  discoverer  and 
while  the  series  of  incandescent  lamps  necessarily  radiate 
heat,  Kellogg's  apparatus  can  scarcely  be  counted  among 
the  hot-air  apparatus. 

Bier  speaks  favorably  of  Frcy's  air  douche.     Air  forced 


Fig.  4. 
Betz1  Body  Hot-Air  Apparatus. 

by  an  electric  motor  fan  passes  through  two  systems  of 
piping,  one  of  which  can  be  heated  up  to  200°  C,  while 
the  other  can  be  cooled  by  means  of  ice  and  common  salt 
to  — 10°  C.  By  a  simple  device  the  temperature  of  the  air 
can  be  regulated  and  kept  even.  Frcy  in  several  contribu- 
tions has  written  extensively  on  the  subject  (36).  Taylor 
(37),  on  a  similar  principle  to  Prey's  air  douche,  has  con- 
structed a  very  complicated  apparatus  which  he  has 
called  "electro  thermogen,"  for  the  treatment  of  neu- 
ralgia. 

The  author  has  had  no  experience  with  the  last  two 


45 

named  but  believes  them  to  be  useful.    As  they  require 
electricity  and  as  they  are  very  expensive  they  are  hardly . 
adapted    for    private    practice    but    should    be    found    in 
thoroughly  equipped  hospitals. 

Here  in  America  several  firms  have  tried  to  introduce 
several  makes  of  hot-air  apparatus.  The  editor  remem- 
bers that  Tallerman's  apparatus  was  to  be  obtained  on 
a  rental  only.  Other  apparatus  are  too  clumsy  and 
expensive  to  be  adopted  by  general  practitioners. 

Betz'  hot-air  apparatus  has  become  so  popular  that  a 
description  of  it  is  scarcely  necessary.  In  principle  it 
consists  of  metal  cylinders,  lined  with  asbestos.  At  the 
bottom  is  a  large  opening  into  which  is  inserted  a  sjiort 
pipe  terminating  into  a  funnel.  The  top  has  two  open- 
ings :  one  for  a  thermometer  and  one  for  the  purpose  of 
ventilation.  The  Betz  apparatus  has  an  ingeniously  con- 
structed heat  carrier,  placed  on  the  bottom  of  the  interior 
which  distributes  the  heat  evenly  throughout  the  cylinder. 
The  arm  or  leg  can  be  inserted  and  rests  on  a  hammock. 
When  it  is  desired  to  direct  the  heat  toward  a  large  joint 
or  region  of  the  body,  cuff  attachments  are  used,  which 
also  prevent  the  heated  air  from  passing  out.  The 
heat  is  obtained  from  either  a  gas  burner,  alcohol  lamp 
or  a  specially  constructed  gasoline  burner.  These  burners 
are  so  constructed  that  they  can  be  easily  regulated  in 
regard  to  the  intensity  of  the  flame.  The  burners  them- 
selves can  be  raised  or  lowered. 

Betz'  apparatus  is  comparatively  inexpensive  and  dur- 
able. The  arm  and  leg  apparatus  is  practically  a  uni- 
versal hot-air  apparatus.  A  special  apparatus  has  been 
constructed  for  the  knee-joint. 

Figs,  i,  2,  3  and  4  illustrate  the  Betz  apparatus.  Special 
descriptive  circulars  can  be  easily  obtained  from  the  well- 
known  makers  of  surgical  instruments,  hospital  apparatus 
and  therapeutic  appliances,  Frank  S.  Betz  Co.,  Chicago. 


CHAPTER  V 

LOCAL  AND  GENERAL  EFFECTS  OF  HOT-AIR 
BATHS  ON  THE  BODY 

I  do  not  intend  to  discuss  here  the  therapeutic  proper- 
ties of  hot-air  baths,  as  I  will  describe  these  later  in  con- 
nection with  other  methods  for  the  production  of  hyper- 
emia,  which  either  act  alike  or  because  they  produce 
different  forms  of  hyperemia,  occasionally  have  the 
opposite  effect.  All  I  am  at  present  concerned  in  is  to 
discuss  the  changes  which  the  treated  part  or  body 
undergo  when  subjected  to  the  influence  of  hot  air.  ,  A 
limb  placed  in  the  hot-air  cylinder  described  above  usu- 
ally commences  to  feel  moist  at  a  temperature  of  about 
50°  C.  At  60-70°  it  commences  to  perspire  more  freely. 
If  the  limb  be  exposed  for  some  time  to  a  temperature  of 
100°  the  perspiration  is  so  free  that  it  falls  from  the  limb 
in  drops.  If  the  heat  be  raised  higher  still  up  to  the  point 
of  endurance  (114°)  perspiration  apparently  becomes 
less;  in  this  I  agree  with  Schreiber.  However  I  am  not 
so  sure  whether,  as  is  the  opinion  of  Schreiber,  the  intense 
irritation  of  the  sweat-producing  apparatus  produces  a 
diminution  of  the  perspiration  in  a  form  of  paralysis,  or 
whether  the  greater  evaporation  simply  removes  the 
sweat.  At  any  rate,  as  far  as  I  can  remember,  I  have 
never  observed  the  bright  red  dry  limbs  which  he  has 
seen  after  the  use  of  high  degrees  of  heat. 

My  arm  becomes  slightly  and  unevenly  red  after  a  pro- 
longed exposure  to  air  at  about  70°,  at  80-100°  the  color 
becomes  more  pronounced  and  if  I  heat  the  air  to  the 
point  of  endurance  enormously  so  and  evenly.  We  can 
establish  it  as  a  rule  that  the  hyperemia  gradually  in- 
creases with  the  degree  of  temperature  and  length  of 
application  (provided  an  hour  is  not  exceeded). 

If  burns  are  avoided  the  entire  process  is  by  no  means 
unpleasant,  on  the  contrary  the  heat  affects  the  limb 
agreeably. 

After  the  bright  red,  perspiring  limb  is  removed  from 
the  apparatus,  dried  and  dressed,  the  pleasant  effect 
remains  for  some  time  and  occasionally  this  sensation  of 

46 


EFFECTS   OF  HOT-AIR   BATHS 


47 


increased  temperature  remains  in  the  treated  limb  for 
hours.  Measurement  with  the  surface  thermometer 
shows  objectively  a  decided  after-effect. 

It  can  regularly  be  demonstrated  that  that  part  of  the 
body  which  has  been  exposed  to  hot  air  has  an  increased 
temperature  of  the  skin  an  hour  or  more  after  removal 
from  the  apparatus.  It  goes  without  saying  that  the 
measurements  should  be  made  on  the  same  identical 
places  under  equal  conditions.  I  cite  the  following  cases 
as  examples : 


V 

h 

«£  <" 

-2           — 

oj  u  <L> 

Ou 

i-     . 

u    . 

PART  OF  BODY  AND  DISEASE. 

d  D  cs 

•a  -5 

s«« 

c« 

o  <i> 

X  rt 

§2 
ffirt 

P*^  ?\ 

E     <u 

cc>—  ' 

i—  t^ 

^-t* 

H    H 

B    £ 

* 

" 

Pelvic  and  lumbar  regions  (lum- 

(baero)  .  . 

34.8° 

36.2° 

35.9° 

35.2° 

34.8° 

Second  measurement      

34  9° 

36  0° 

35  8° 

35.4° 

34  8° 

Knee  (hydrops  genu)  

34.6° 

35.8° 

35.5° 

35.1° 

34.6° 

Second  measurement  

34.5° 

35.6° 

35.5° 

35.0° 

34.4° 

Leg  (edema)  

34.2° 

35.9° 

35.5° 

34.8° 

34.1° 

Pelvic  and  lumbar  regions  (sciatica 
scoleotrica)  

34.9° 

36.1° 

35.6° 

35.4° 

34.8° 

Second  measurement  

34.6° 

35.7° 

35.4° 

34.7° 

Third  measurement     

34  9° 

35.6° 

35.3° 

Fourth  measurement  

34.8° 

36.2° 

35.8° 

35.6° 

In  all  these  cases  the  diseased  parts  were  exposed  for 
one  hour  to  a  temperature  as  high  as  could  be  borne  withr 
out  discomfort. 

Aside  from  these  local  effects  the  patient's  body  expe- 
riences also  general  ones.  As  an  example,  though  only 
the  forearm  be  exposed  to  heat  the  entire  body  sweats, 
in  one  more,  in  another  less.  Personally  I  sweat  but  little 
throughout  the  body  while  my  forearm  is  under  -treat- 
ment,  while  others,  especially  obese  or  weak  persons, 
sweat  considerably.  On  the  whole,  in  otherwise  healthy 
individuals  the  general  phenomena  are  relatively  insig- 
nificant, as  compared  with  other  forms  of  high  degrees  of 
heat,  and  this  is  the  unanimous  conclusion  from  expe- 
rience. Thus  Krause  found  an  increase  of  bodily  tempera- 


48  EFFECTS  OF  HOT-AIR  BATHS 

ture  of  y2°  to  a  maximum  of  i°  and  of  5-8  pulse  beats; 
Reitler  an  increase  in  respiration  of  3-5  and  of  the  pulse 
of  10-20;  Mendelsohn,  in  spite  of  a  two-hour  effect  on  the 
forearm  of  air  heated  to  140°  (?)  found  an  average  rise 
of  bodily  temperature  of  0.4-0.6°,  the  pulse  accelerated  by 
4-8  beats.  Other  observers  report  similar  observations. 
My  own  observations  in  regard  to  the  bodily  tempera- 
ture undertaken  in  1891,  show  similar  results  at  a  tem- 
perature of  105°.  However,  when  heating  larger  parts 
(pelvis),  I  have  frequently  observed  a  decided  accelera- 
tion of  the  pulse. 

For  some  individuals  the  treatment  is  not  entirelv 
harmless,  and  below  I  will  discuss  the  obnoxious  and 
disagreeable  consequences  which  the  procedure  may 
have. 

Not  infrequently  slight  burns  of  the  first  and  second 
degree  occur  without  the  patient  noticing  it.  This  is 
probably  due  to  the  fact,  as  I  will  demonstrate  later,  that 
the  intense  hyperemia  reduces  the  sensibility  to  such  an 
extent  that  the  pain  due  to  the  heat  is  not  noticed.  These 
burns  are  usually  insignificant  and  heal  rapidly. 

Very  often,  after  prolonged  application  of  hot  air,  one 
may  observe  dirty  brown  discolorations  of  the  skin  in  the 
form  of  spots  and  network.  Evidently  this  is  decomposed 
blood  coloring  matter  due  to  insignificant  burns.  That 
the  latter  lead  to  disintegration  of  the  red  blood  cor- 
puscles is  known  from  the  experiments  by  Lesser  (38) 
and  others.  Frequently  this  discoloration  follows  the 
course  of  the  small  veins  of  the  skin,  in  which  the  blood 
on  account  of  the  slow  stream  is  mostly  exposed  to  the 
influence  of  the  heat.  Evidently  the  red  blood  corpuscles 
of  some  individuals  are  weak,  for  while  some  do  not  get 
these  spots  at  all,  others  in  whom  no  burns  in  a  clinical 
sense  can  be  observed  show  such  widespread  discolora- 
tions that  the  skin  of  the  treated  area  looks  marbled.  This 
looks  very  ugly,  but  we  may  console  the  patient  with  the 
assurance  that  these  spots  will  disappear  slowly  but 
surely  without  any  treatment. 

Really  harmful  consequences  from  extensive  decom- 
position of  blood,  which  theoretically  would  seem  pos- 
sible, I  have  never  seen. 

A  disadvantage,  from  which  hot-air  therapy  can  not 


EFFECTS   OF    HOT-AIR    BATHS  49 

be  freed,  is  the  fact  that  it  makes  large  demands  on  the 
general  strength  of  the  patient,  especially  when  extensive 
surfaces  are  subject  to  hot  air.  In  anemic  persons  treat- 
ments are  followed  by  headache,  exhaustion  and  lassitude. 
I  have  not  infrequently  observed  palpitation  of  the  heart. 
( Hhers  have  reported  even  fainting  spells.  However, 
these  unpleasant  after-effects  are  not  frequent.  They  can 
be  minimized  or  altogether  avoided  by  applying  in  such 
individuals,  cold  compresses  to  the  head  during  the  treat- 
ment, avoidance  of  unusually  large  surfaces  and  by  per- 
mitting the  patients  to  rest  before  and  after  treatment,  in 
short,  the  usual  precautions  customary  in  vapor  and  sand 
baths.  The  length  of  each  seance  should  be  carefully 
regulated,  beginning  with  short  ones  and  increasing  the 
duration  gradually.  The  choice  of  the  time  in  the  day  is 
not  without  importance,  which  in  each  individual  case 
must  be  determined  by  experiment. 

If  in  spite  of  these  precautionary  measures  these  sym- 
toms  still  occur,  it  is  best  to  abandon  the  hot-air  treat- 
ments and  to  change  with  one  of  the  other  processes  for 
the  production  of  hyperemia  which  we  will  later  discuss, 
and  which,  though  acting  similarly  to  hot  air,  are  less 
effective  constitutionally. 

Naturally  chilling  should  be  avoided.  As  already  men- 
tioned, the  bodies  of  some  men  sweat  considerably  even 
when  only  a  part  of  an  extremity  is  exposed  to  hot  air. 
Such  individuals  must  be  rubbed  dry,  if  possible  the  cloth-- 
ing should  be  changed  and  they  should  remain  for  at 
least 'an  hour  in  a  warm  room,  and  rest.  If  the  patients 
are  compelled  to  go  into  the  free  air  sooner,  they  should 
at  least  take  some  exercise.  These  are  well-known  rules 
in  hydrotherapy. 

Hot  air  should  not  be  employed  too  long.  In  the  larg- 
est majority  of  cases  we  limit  it  to  one  hour.  Only 
exceptionally  in  stubborn  joint  effusions,  we  allow  the 
use  of  this  remedy  twice  daily  for  one  hour,  when  needed. 
At  first  I  used  hot  air  excessively  for  many  hours  daily 
in  tuberculous  affections  of  the  extremities.  This  event- 
ually leads  to  an  hyperemia  which  does  not  disappear 
during  the  intervals  and  even  to  edema.  Granulations  dry 
up  superficially  but  under  the  dry  cover  they  become  so 
strongly  hyperemic  that  serious  hemorrhages  are  apt  to 


50  EFFECTS   OF   HOT-AIR    BATHS 

occur.  In  1891  I  treated  a  large  tuberculous  ulcer  eight 
to  ten  hours  daily  with  air  at  100°.  The  intensely  hyper- 
emic  granulations  twice  bled  so  profusely  that  I  could 
stop  it  with  difficulty  by  means  of  compression  and 
elevation. 

Finally  I  will  mention  that  hot-air  therapy,  as  may  be 
expected  from  so  effective  a  process,  influences  appetite 
and  metabolism.  While  some  individuals  are  not  at  all  in- 
fluenced by  it,  others  complain  of  lack  of  appetite  and 
with  these  the  treatment  should  never  be  instituted  close 
to  or  after  a  meal.  Others  again  get  a  good  appetite  and  a 
strong  desire  for  food.  Thus,  I  recently  treated  a  gentle- 
man with  hot  air  applied  to  the  pelvis,  who  became  enor- 
mously hyperemic  and  perspired  freely.  He  was  very 
much  astonished  at  the  pronounced  appetite  which  he 
experienced  after  the  treatment.  On  the  other  hand, 
thirst  appears  less  than  one  would  expect,  a  phenomenon 
with  which  we  are  acquainted  in  the  employment  of  other 
methods  of  heat,  which  produce  perspiration. 


. 

CHAPTER  VI 

PRODUCTION  OF  PASSIVE  HYPEREMIA 

It  required  a  good  deal  of  discussion  on  my  part  to 
establish  that  the  application  of  heat  in  .the  manner 
described  is  the  best  means  of  producing  active  hyper- 
emia, and  it  required  detailed  proof  that  the  hyperemia  is 
the  essential  effective  curative  agent  in  the  affections  of 
interest  to  us,  because  the  influence  of  this  remedy  was 
always  altogether  differently  conceived.  In  the  measures 
we  are  about  to  describe  no  one  will  be  in  doubt  that  they 
act  solely  by  hyperemia  and  that  it  is  a  passive  hyperemia 
which  we  produce.  On  the  other  hand,  with  some  of  the 
agents  (cupping  glasses  and  suction  apparatus)  it  is 
doubtful  whether  they  produce  an  arterial  or  venous 
hyperemia.  At  any  rate,  it  is  sometimes  a  matter  of  view 
whether  we  should  call  a  hyperemia  arterial  or  venous,  as 
they  unnoticeably  blend  one  into  the  other.  In  the  largest 
majority  of  cases,  however,  one  can  not  be  in  doubt  as  to 
the  kind  of  hyperemia. 

Passive  hyperemia  has  already  been  employed  by  me 
for  purpose  of  nutrition  and  in  the  cure  of  bone  fractures 
which  would  not  knit,  and  if  the  widely  used  expression 
"Bier's  stasis"  is  to  mean  that  I  have  introduced  the 
technic  of  stasis  hyperemia  and  this  name  is  used  even 
in  the  treatment  of  bone  fractures,  I  must  decline  this. 
Much  rather  can  I  claim  for  myself  the  introduction  of 
hot-air  apparatus,  which  are  often  named  after  Taller- 
man,  because  mine  were  present  long  before  his  and 
further  because  mine,  for  general  use,  are  much  more  use- 
ful and  practical  and  for  this  reason  have  been  widely 
adopted  either  in  their  original  form  or  in  one  of  their 
numerous  modifications. 

But  except  for  bone  fractures  and  for  attempts  at 
nutrition,  before  me  no  one  has  employed  stasis  hyper- 
emia, nay,  warnings  have  been  uttered  against  blood - 
stasis  in  the  affections  for  which  I  have  recommended  it, 
the  main  duty  of  the  physician  having  been  interpreted 
as  one  to  remove  and  combat  the  inflammatory  stasis 
hyperemia  by  means  of  the  so-called  antiphloglosis.  This 
idea  is  so  deeply  rooted  in  the  minds  of  modern  physicians 

61 


\\^\         •"'-'-  I'KOI  AUCTION   OF    PASSIVE    HYPEREMIA 

that  the  majority  of  them  even  to-day  have  an  antipathy 
against  the  employment  of  this  remedy  and  for  this  rea- 
son it  is  used  in  but  few  places.  But  I  am  convinced  that 
it  has  a  great  future  and  that  the  time  is  not  very  far  dis- 
tant when  physicians  will  appreciate  that  the  employment 
of  this  form  of  hyperemia  is  not  only  useful  in  a  large 
number  of  affections  but  also  based  on  logic  and  science. 

And  this  much  I  must  claim  for  myself,  that  I  have 
pointed  out  to  therapy  an  entirely  new  avenue  and  have 
originated  the  teaching  of  the  rational  employment  of 
hyperemia,  which  heretofore  has  not  even  been  men- 
tioned, though  used  unconsciously. 

It  seems  that  the  first  to  have  hit  upon  the  idea  to 
make  use  of  artificial  stasis  hyperemia  in  insufficient 
callus  formation  was  Ambroise  Pare  (39).  In  the  thir- 
tieth chapter  of  the  thirteenth  book  of  his  works  he  at 
first  recites  the  remedies  for  the  reduction  of  callus  when 
too  large.  These  consist  in  diminishing,  dividing  and 
astringent  substances.  "If,  however,  the  callus  is  too 
small  and  undeveloped  in  consequence  of  the  bandage 
being  too  tight  or  because  the  limb  has  been  too  long 
at  rest  without  exercise  or  the  nutrition  of  the  patient 
was  insufficient,  the  bandage  has  to  be  taken  off  and 
entirely  removed  from  the  fracture.  Instead  a  different 
kind  of  bandage  should  be  applied  beginning  at  the  root 
of  the  vessels,  if  on  the  leg  close  to  the  inguinal  region, 
if  on  the  arm  near  the  shoulder  and  reaching  nearly  to  the 
seat  of  the  fracture.  For  by  this  remedy  the  blood  is 
squeezed  out  and  compelled  to  flow  to  the  injured  place." 

I  do  not  know  whether  Fare's  idea  to  effect  nutrition 
and  callus  formation  by  means  of  artificial  stasis  hyper- 
emia has  found  followers.  Probably  ft  has  been  entirely 
forgotten,  which  is  natural,  to  judge  from  the  brevity  and 
lack  of  clearness  of  the  contribution,  until  Nicoladoni 
(40)  described  in  the  year  1875  v.  Dumreicher's  method, 
which  he  recommended  for  threatening  pseudo-arthroses 
without  being  acquainted  with  Fare's  experiments,  v. 
Dumreicher's  idea,  to  use  Nicoladoni's  words  was :  "Per- 
haps we  will  succeed  in  reaching  our  goal  if  we  are  able 
to  send  a  larger  quantity  of  nutritive  material  to  the 
threatened  place.  If  we  can  still  more  fill  the  vessels  and 
if  the  tissues  are  in  a  condition  fit  to  take  up  the  material 


PRODUCTION   OF   PASSIVE   HYPEREMIA  53 

of  which  we  now  have  an  abundance,  an  artificially  pro- 
duced and  permanently  maintained  hyperemia  per  sc  will 
exercise  a  powerful  stimulus  on  the  tissues  and  tissue 
elements  which  participate  in  formation  of  callus  in 
accordance  with  the  relation  of  added  nutrition  to  func- 
tion, so  well  known  to  each  of  us.  A  method  which  has 
this  as  its  aim  fulfills  also  another  indication,  viz. :  that 
the  once  stimulated  production  receive  continuously  ma- 
terial to  carry  out  the  construction  of  callus  until 
finished." 

In  principle  Xicoladoni  produced  hyperemia  exactly  as 
we  produce  it  even  to-day,  namely,  by  means  of  an  incom- 
plete v.  Esmarch  bloodlessness  with  rubber  tubing 
loosely  applied  over  the  seat  of  fracture,  while  that  part 
of  the  limb  situated  below  the  fracture  was  bandaged 
with  a  flannel  bandage.  He,  however,  considered  v.  Dum- 
reicher's  original  method  more  effective,  which  is  carried 
out  in  the  following  manner :  The  limb  below  the  frac- 
ture is  firmly  wrapped  by  a  flannel  bandage  with  the 
view  of  damming  the  arterial  blood-stream  and  of  direct- 
ing it  away  from  the  bandaged  part  towards  the  place  of 
the  fracture.  Here  stasis  hyperemia  is  produced  by 
wedge-shaped  compresses  placed  above  and  below  (Nico- 
ladoni  speaks  only  of  fracture  of  the  shinbone)  with  their 
broad  ends  turned  toward  the  bone  fracture.,  A  bridge 
in  the  form  of  a  wooden  splint  presses  the  wedges  tight 
against  the  bone  while  a  firmly  drawn  roller  bandage 
keeps  the  whole  in  place.  The  wedges  produce  an 
intense  hyperemia  in  the  place  of  the  fracture  free  from 
the  pressure,  embracing,  as  Nicoladoni  has  demonstrated, 
the  entire  bone  down  to  the  marrow. 

Except  in  threatened  pseudo-arthroses  this  process  has 
also  been  successfully  employed  in  order  to  more  quickly 
fill  bone  cavities. 

Xicoladoni,  in  different  places,  points  to  the  similarity 
of  the  phenomena  produced  by  this  method  with  acute 
inflammation  not  limited  to  the  development  of  a  simple 
edema  but  similar  also  in  the  hardness  of  the  swollen 
tissues  produced  by  inflammation. 

Although  Xicoladoni  has  thus  described  in  detail  the 
effect  of  stasis  hyperemia  on  the  development  of  callus 
and  bone  regeneration  in  bone  cavities,  apparently  the 


54  PRODUCTION   OF   PASSIVE  HYPEREMIA 

usefulness  of  this  procedure  has  not  been  recognized  but 
fairly  neglected.  Bruns  (41)  in  his  book  on  bone-frac- 
tures, cites  in  the  year  1886  only  five  cases  in  which  v. 
Dumreicher's  method  had  been  employed. 

But  in  the  same  year  appeared  an  elaborate  contribu- 
tion tfy  Thomas  (42)  on  the  effect  of  stasis  hyperemia  on 
bone  fractures  with  retarded  callus  formation.  He  nar- 
rates fourteen  cases  in  which  he  has  employed  this 
method. 

In  the  first  few  cases  he  simply  applied  a  tourniquet 
above  the  seat  of  fracture  and  let  it  remain  for  only  half 
an  hour  daily.  Later,  however,  he  used  prolonged  hyper- 
emia and  attempted  to  confine  it  especially  to  the  place 
of  fracture  by  applying  a  ru-bber  bandage  above  and 
below  so  firmly  that  stasis  developed  in  its  region.  He 
depicts  the  method  by  an  illustration.  In  order  to  increase 
the  hyperemia  Thomas  let  the  limb  hang  down. 

Of  the  fourteen  cases,  Thomas  treated  but  four  with 
stasis  hyperemia  exclusively.  In  the  other  ten  cases  he 
used  besides  an  older  method  of  percussion,  viz.,  he  per- 
cussed the  fractured  ends  at  intervals  of  a  few  days  to 
months  wifh  a  hammer  covered  with  rubber,  while  pro- 
tecting the  skin  against  injury  with  a  layer  of  felt.  He 
intended  to  excite  an  inflammatory  irritation  by  this  per- 
cussion and  from  the  histories  it  can  be  seen  that  he  was 
successful  in  this.  He  produced  by  it  swelling  and  fre- 
quently bloody  discoloration  in  the  region  of  the  fracture  ; 
that  he  proceeded  energetically  can  be  concluded  because 
he  frequently  undertook  this  operation  under  ether 
anesthesia.  The  excellent  results  which  Thomas 
achieved  in  several  grave  and  hopeless  cases  make  it 
apparent  that  the  combination  of  these  two  remedies  is 
very  useful. 

Thomas  successfully  utilized  this  procedure,  which  he 
terms  "damming,"  in  two  cases  of  recent  fracture  of  the 
patella  and  in  one  case  in  which  the  quadriceps  tendon 
was  torn. 

Thomas  does  not  mention  v.  Dumreicher  or  Nicoladoni 
and  wrongly  thinks  he  is  the  inventor  of  the  method,  as 
he  expresses  himself  in  several  places. 

In  the  following  year  Helferich  (43)  recommended 
anew  the  stasis  hyperemia,  to  increase  deficient  callus 


PRODUCTION   OF   PASSIVE   HYPEREMIA  55 

formation  and  in  general  to  stimulate  bone  regeneration 
and  bone  growth.  He  produces  hyperemia  in  the  manner 
described  by  Nicoladoni  as  less  effective,  by  loosely  plac- 
ing above  the  diseased  place  of  the  bone  a  piece  of  rubber 
tubing,  but  firmly  enough  to  create  below  a  vigorous 
venous  hyperemia.  In  order  to  limit  the  stasis  to  the 
diseased  portion  of  the  limb  a  bandage  is  applied  up  to  it. 
Helferich  lets  the  limb  hang  down  in  order  to  make  the 
hyperemia  intense.  Rightly  Helferich  points  out  that 
this  method  is  simpler  than  the  complicated  one  of 
Dumreicher  and  that  the  peripheral  of  the  two  rubber 
bandages  which  Thomas  applies  is  superfluous. 

He  reports  eight  cases  of  retarded  callus  formation  in 
which  he  has  successfully  employed  stasis  hyperemia 
exclusively,  and  three  other  cases  in  which  he  previously 
nailed  together  the  fractured  ends.  We  will  later  on 
more  fully  discuss  his  experiments  to  stimulate  bone 
growth  by  the  same  agent. 


PASSIVE    HYPEREMIA    OF   THE    LIMBS* BY    A 
STASIS  BANDAGE 

This,  in  practice,  is  the  most  important  process  and  has 
early  been  employed  for  the  cure  of  pseudo-arthroses. 

The  rubber  bandage  is  to  be  applied  above  the  place 
which  is  to  be  rendered  hyperemic,  in  several  turns  cover- 
ing each  other,  firmly  enough  to  compress  the  weaker 
walls  of  the  veins  but  not  the  stronger  ones  of  the  arter- 
ies. Depending  on  the  firmness  of  the  application  we  can 
produce  any  degree  of  stasis  hyperemia  varying  from  the 
mildest  to  the  most  intense  form.  The  changes  which 
take  place  in  the  extremities  thus  subjected  to  stasis 
I  can  best  describe  by  some  experiments  on  myself. 

I  apply  to  my  left  upper  arm  a  stasis  bandage  so  as 
to  produce  a  mild  passive  hyperemia.  The  bandage  is 
applied  only  firmly  enough  so  as  not  to  produce  any 
inconvenience  and  that  in  attending  to  one's  customary 
occupation  it  is  forgotten. 

First  the  subcutaneous  veins  of  the  back  of  the  hand 
swell,  next  the  large,  subcutaneous  veins  on  the  flexor 
side  of  the  forearm.  The  skin  of  the  arm  gradually 
assumes  a  bluish  color,  while  the  palm  of  the  hand  and 
the  extensor  side  of  the  elbow  assume  a  rosy  color.  The 
back  of  the  hand  and  fingers  are  generally  bright  red.  In 
the  skin  of  the  palm  one  can  observe  numerous  circuni  - 
scribed  white  spots  varying  in  size  from  a  millet  to  a 
lentil.  These  can  also  be  found  sparingly  on  the  back  of 
the  hand-  On  careful  inspection  one  can  plainly  observe 
the  otherwise  invisible  neat  net  of  the  veins  of  the  cutis. 

After  three  hours  the  skin  of  the  forearm  is  equally 
blue-red.  The  fingers,  the  region  of  the  elbow  and  the 
back  of  the  hand  are  bright  red,  the  last,  however,  is 
blue-red  around  the  larger  vein  trunks.  The  white  spots 
on  the  skin  of  the  palm  are  faded  and  can  scarcely  bo 
seen.  The  large  subcutaneous  veins  are  less  prominent, 
the  net  of  superficial  cutaneous  veins  begins  to  fade.  Pro- 
longed, strong  pressure  with  the  finger  on  the  back  of 
the  hand  demonstrates  an  incipient  edema.  The  pulse  is 
full  and  forcible,  rather  stronger  than  in  the  other  arm. 

56 


PASSIVE   HYPEREMIA    BY   STASIS   BANDAGE  57 

The  treated  limb  is  more  susceptible  to  cold  than  the 
other  one.  Pressure  with  the  finger  blanches  the  skin 
everywhere,  and  becomes  refilled  immediately  with  ve- 
nous blood.  Friction  produces  even  in  the  bluish  discol- 
ored places  the  most  vigorous  arterial  bright  red,  which 
remains  for  quite  a  while. 

After  the  bandage  has  remained  in  situ  ten  hours  the 
increasing  edema  becomes  striking.  The  largest  circum- 
ference of  the  left  forearm  is  2  cm.  more  than  previous 
to  the  institution  of  the  stasis.  The  impression  from  the 
finger  remains.  After  twenty  hours,  arm  and  back  of 
hand  are  equally  swollen  by  edema,  the  largest  circumfer- 
ence now  being  increased  by  2^  cm.  The  skin  of  the 
fingers,  of  the  palm,  the  back  of  the  elbow  and  wrist 
joints  are  still  bright  red,  the  rest  of  the  skin  bluish  red. 
The  subcutaneous  veins  are  but  faintly  visible,  no  more 
so  than  on  the  untreated  arm.  They  are  not  only  covered 
by  the  edema  but  they  can  not  be  felt  any  more  like  in  the 
beginning  as  tightly  stretched  cords.  Forcible  friction  on 
a  bluish  red  place  produces  even  now  a  decided  bright 
arterial  redness. 

That  there  exists  no  crude  obstacle  for  the  return  flow 
of  the  venous  blood  is  evident  from  the  fact  that  when 
I  stretch  my  arms  (the  well-known  experiment  of  the 
flow  of  venous  blood  toward  the  thorax)  the  arm 
blanches  almost  immediately. 

Immediately  after  the  undressing  both  arms  feel 
equally  warm.  After  remaining  undressed  for  some  time 
the  treated  arm  feels  somewhat  colder.  After  a  prolonged 
exposure  to  cold  (-f-2°C.  with  wind)  on  the  uncovered 
back  of  the  hand  of  the  treated  extremity  appear  ver- 
milion spots,  which  disappear  on  pressure  with  the  finger 
and  reappear  immediately. 

This  degree  of  stasis  on  a  healthy  arm  produces  little  or 
no  reduction  of  the  temperature  of  the  skin. 
An  experiment  on  my  arm  shows : 

Previous  to  stasis 31.8° 

Ten  minutes  later 31 .0° 

After  an  hour 31 .9° 

After  about  i*/2  hours '. 32.5° 

Immediately  after  the  removal  of  the   • 
bandage  after  i  -j4  hours 32 . 2° 


58  PASSIVE  HYPEREMIA   BY  STASIS  BANDAGE 

If  the  rubber  bandage  is  applied  just  as  firmly  on  an 
inflamed  extremity  the  consequent  conditions  are  gener- 
ally more  pronounced  and  this  in  proportion  to  the  inten- 
sity of  the  inflammation.  As  is  well  known  all  inflamed 
limbs  are  warmer  at  the  affected  place.  Even  in  chronic 
tuberculous  inflammations  this  increase  of  temperature  is 
considerable.  The  differences,  as  compared  with  the 
same  place  of  the  healthy  limb,  range  between  1-3°  C.  and 
more  in  favor  of  the  affected  part. 

I  remark  that  the  comparative  measurements  must  be 
undertaken  in  exactly  symmetrical  places  and  under 
equal  conditions.  One  must  not,  for  instance,  place  the 
two  uncovered  extremities  alongside  each  other  and  then 
proceed  to  measure  first  the  one  and  then  the  other,  be- 
cause the  latter  in  the  meantime  has  cooled  off.  The 
former  also  is  important,  because  different  places  of  the 
same  part  of  the  extremity  have  normally  a  variable  tem- 
perature. 

Thus,  for  reasons  easily  understood,  the  skin  of  the 
palm  is  always  warmer  than  that  of  the  back  of  the 
hand. 

In  contrast  to  this  moderate  stasis  hyperemia,  which 
is  the  one  mostly  employed  in  practice,  I  .now  proceed  to 
describe  the  phenomena  produced  by  a  firmly  applied 
bandage.  Anspitz  (44)  has  excellently  and  minutely 
described  them  in  1874.  The  observations  made  by  me 
on  myself  and  on  one  of  my  assistants  are  almost  totally 
in  accord  with  those  made  by  Anspitz.  I  differ  from  him 
only  in  the  interpretation  of  the  phenomena  in  many 
points. 

I  apply  to  my  left  upper  arm  a  rubber  bandage  so 
firmly  that  it  produces  the  strongest  possible  venous 
stasis.  Below  the  bandage  I  feel  the  pulsating,  beating 
artery.  Even  after  two  minutes  the  subcutaneous  veins 
swell  very  much  and  the  skin  becomes  livid,  its  shade 
being  bluish  to  grayish  red.  In  the  palm  one  can  observe 
several  bright  red  spots,  while  on  the  posterior  side  of  the 
elbow,  on  the  back  of  the  hand  and  on  the  radial  side  of 
the  forearm  below  the  stasis  bandage  appear  vermilion 
and  yellow  spots.  The  vermilion  spots  increase  and  en- 
large and  become  confluent  so  that  after  seven  minutes 
the  largest  part  of  the  skin  is  vermilion.  The  bluish  red- 


PASSIVE   HYPEREMIA  BY  STASIS  BANDAGE  59 

ness  remains  longest  in  the  middle  of  the  flexor  side  of 
the  forearm  and  on  the  back  of  the  hand.  Pressure  on 
the  vermilion  skin  produces  a  white  spot  which  imme- 
diately after  the  cessation  of  pressure  reassumes  its  color. 
On  the  flexor  side  below  the  stasis  bandage  develop 
numerous  carmine  red  points  (small  hemorrhages).  In 
the  arm  appear  sensations  of  heaviness,  fatigue,  prick- 
ling and  cold  and  warm  alternately.  The  fingers  feel  cold. 
After  twenty  minutes  the  skin  of  almost  the  entire  con- 
stricted arm  becomes  vermilion ;  the  blue-colored  places 
have  still  more  receded.  By  friction  on  the  back  of  the 
hand  a  vivid  bright  hyperemia  can  be  produced.  The 
skin  does  not  assume  a  rosy  hue  but  has  a  decided  shade 
partially  yellowish,  partially  copper-color.  The  point-like 
hemorrhages  increase.  The  tightly  stretched  subcu- 
taneous veins  are  less  visible  and  perceptible  to  touch. 
Yellowish  white  spots  develop  in  the  palm  and  on  the 
tips  of  the  fingers.  The  limb  becomes  numb  and  cold  to 
the  feel,  but  subjectively  one  has  a  sensation  of  warmth 
in  the  arm. 

In  the  course  of  the  stasis  the  skin  of  the  palm  becomes 
ashen  gray,  interspersed  by  vermilion  and  white  spots. 
The  vermilion  spots  become  white  on  pressure  with  the 
finger  and  then  one  can  see  on  that  place  numerous  point- 
like  hemorrhages ;  after  cessation  of  the  pressure,  the 
vermilion  color  reappears  rapidly. 

After  forty  minutes  the  intense  stasis  produces  an  intol- . 
erable  sensation  of  pain,  so  that  the  bandage  must  be 
loosened.  I  at  once  experience  a  decided  sensation  of 
cold  in  the  arm  and  a  feeling  as  if  it  were  faradized. 
These  sensations  are  most  pronounced  in  the  tips  of  the 
fingers.  The  skin  in  the  part  of  the  limb  which  has  been 
constricted  commences  to  assume  a  rose  color  in  about 
the  same  degree  as  is  observed  in  artificial  bloodlessness 
which  had  been  employed  for  three  to  four  minutes,  only 
the  fingers  remain  deathly  pale  for  a  little  while,  similar 
to  that  observed  in  some  individuals  after  a  cold  bath. 
One  and  one-half  minutes  later  they  become  bright  red 
and  in  the  entire  limb  appears  a  sensation  of  warmth. 
Even  three-quarters  of  an  liour  after  the  removal  of  the 
bandage  I  still  have  a  sensation  of  stiffness  of  the  muscles 
and  fatigue  in  the  arm.  In  the  skin  one  can  see  numerous 


60  PASSIVE   HYPEREMIA   BY   STASIS   BANDAGE 

carmine  red  point-like  hemorrhages.  After  twenty-four 
hours  these  blood-points  have  faded  and  appear  bright 
to  yellowish  red.  The  skin  of  the  constricted  extremity 
shows  a  decided  yellowish  brown  color,  particularly  so 
in  the  bend  of  the  elbow  and  below.  This  discoloration 
is  in  sharp  contrast  with  the  place  where  the  lowest  mar- 
gin of  the  stasis  bandage  was  applied.  After  two  days  the 
yellow  color  of  the  arm  has  faded  considerably.  The 
blood-points  can  only  be  recognized  on  careful  inspec- 
tion as  yellowish  brown  spots.  After  four  days  every- 
thing has  disappeared ;  the  skin  appears  normal. 

During  the  experiment  the  temperature  of  the  skin  has 
fallen  rapidly.  Previously  it  was  in  the  palm  32.2°,  five 
minutes  after  the  institution  of  the  stasis  30.9°,  after  fif- 
teen minutes  30.0°,  after  thirty  minutes  29.0°.  The  limb 
swells  rapidly ;  as  early  as  ten  minutes  after  the  appear- 
ance of  the  stasis  the  circumference  of  the  arm  has 
increased  2  cm.  Edema  appears  but  to  a  slight  degree 
after  a  duration  of  the  stasis  of  thirty  to  forty  minutes. 

I  differ  in  the  interpretation  of  the  phenomena  in  essen- 
tial points  from  Anspitz.  First  of  all,  that  physician 
believes  that  this  intense  stasis  is  limited  to  the  skin  and 
that  the  deeper  veins  are  compressed  not  at  all  or  incon- 
siderably. This  is  an  error..  Not  only  the  intense  but 
the  above  described  moderate  stasis  affects  the  deepest 
veins  (probably  principally  by  means  of  the  compressed 
main  trunk).  Of  this  one  can  be  convinced  by  applying 
lightly  a  stasis  bandage  above  deep  operative  wounds. 
We  frequently  observe  that  an  intense  stasis  hyperemia 
continues  into  the  very  depths  of  the  limbs,  when  in  op- 
eration an  incorrectly  applied  artificial  bloodlessness  gives 
way,  and  we  thus  get  the  same  phenomena  which  I  have 
just  described  under  intense  stasis.  This  hyperemia  even 
reaches  the  very  bone,  for  one  can  observe  an  increased 
flow  of  venous  blood  from  the  medullary  cavity  of  the 
sawed  or  chiseled  through  bone. 

I  have  described  some  time  ago  (45)  that  in  total 
obstruction  to  the  return  flow  of  venous  blood  a  part  of 
the  stased  blood  goes  back  through  the  bone,  the  vessels 
of  which  naturally  are  not  concerned  in  the  pressure  of 
the  constricting  subject.  We  therefore  succeed  in  render- 


PASSIVE   HYPEREMIA  BY  STASIS   BANDAGE  61 

ing  hyperemic,  by  means  of  the  stasis  bandage,  the  very 
bone  into  its  marrow. 

Anspitz  thinks  that  the  vermilion  spots  which  appear 
in  intense  stasis  are  produced  by  blood  coloring  matter 
which  enters  the  tissues ;  that  the  latter  plays  an  impor- 
tant role  I  consider  probable.  We  know  through  Strieker 
and  Cohnhciin  that  hemorrhages  occur  per  diapcdcsin 
in  intense  stasis  and  we  observe  point-like  hemorrhages 
and — what  is  still  more  important — yellowish  discolora- 
tions  of  the  skin  of  the  entire  area  subjected  to  hyper- 
emia,  which  can  develop  only  through  coloring  matter  of 
the  blood. 

"\Yhether,  however,  this  is  the  only  reason  for  the 
appearance  of  the  vermilon  color  remains  doubtful  to 
me,  for  we  can  observe  the  same  redness  appear  on  the 
skin  from  short  exposures  to  cold,  which  leads  to  a 
considerable  stasis  of  the  blood  but  not  to  a  discolora- 
tion of  the  skin.  I  also  could  not  convince  myself  as  to 
Anspitz's  statement  that  pressure  with  the  finger  does 
not  cause  the  vermilion  color  to  disappear;  in  my  case 
pressure  always  produced  a  white  spot,  which  quickly 
again  became  red.  I  therefore  leave  unestablished  the 
cause  of  the  development  of  these  vermilion  spots'  and 
only  remark  that  they  are,  when  apparent  in  large  num- 
bers in  an  extensive  area,  the  perceptible  evidence  of  a 
very  intense  and  excessive  stasis. 

As  an  explanation  for  the  white  spots  Anspitz  cites 
partially  mechanical  reasons,  partially  Samuel's  Itio  in 
paries.  I  explain  them  differently.  I  have  already  stated 
that  arteries  and  especially  capillaries  of  external  parts 
of  the  body  fight  against  venous  blood  which  becomes 
stased  in  them  and  push  it  forward  in  the  direction  of 
the  veins  by  means  of  motions  of  their  own.  Only  in  this 
way  can  it  be  explained  why  the  arteries  are  empty  in 
corpses  and  in  extremities  rendered  "bloodless."  It  is 
evidently  erroneous  to  attempt  to  explain  this  by  the 
elasticity  of  the  arteries.  I  have  frequently  convinced 
myself  that  not  only  the  dead  artery  in  the  corpse  but 
also  the  living,  larger  artery  of  the  "bloodless"  limb  is 
flat,  though  it  should  be  round,  if  an  elastic  contraction 
had  expelled  the  blood ;  the  artery  furthermore  gapes 


62  PASSIVE  HYPEREMIA  BY  STASIS  BANDAGE 

wide  open  when  cut  through,  though  it  is  empty  or  con- 
tains only  traces  of  blood. 

v.  Esmarch's  "bloodlessness"  as  generally  applied — 
bandaging  of  the  elevated  limb — is  virtually  no  real  blood- 
lessness, for  it  permits  the  blood  found  in  the  limb  to 
remain  in  it.  In  spite  of  this  the  limb  looks  afterward 
deathly  pale.  If,  however,  an  extremity  is  constricted 
without  undue  haste -with  a  v.  Esmarch  bandage  while 
the  limb  is  in  the  horizontal  posture,  the  normal  amount 
of  blood  would  remain  within,  because  the  first  turns  of 
the  bandage  compress  the  veins  in  front  of  the  arteries. 
If  one  now  observe  this  extremity  it  can  be  seen  that  the 
subcutaneous  veins,  which  previously  were  small,  swell 
considerably,  while  the  rest  of  the  skin  becomes  pale; 
this  happens  even  when  the  limb  hangs  low,  and  in 
surgical  anesthesia  when  muscular  movements  as  a  pro- 
pelling power  for  the  blood  are  excluded.  The  arteries 
and  veins,  therefore,  have  squeezed  out  the  blood  which 
has  become  venous  and  forced  it  into  the  veins. 

The  same  white  spots  which  we  have  noted  above  in 
intense  stasis,  can  be  produced  in  a  greater  measure  and 
more  numerously  by  the  following  experiment:  I  pro- 
duce on  a  man  with  very  white  skin  a  moderate  stasis 
hyperemia  by  means  of  a  few  turns  with  a  rubber  band- 
age applied  to  the  upper  arm  until  the  color  of  the  skin 
becomes  bluish.  Additional  turns  of  the  bandage  made 
firmly  now  shut  off  the  arterial  flow  and  I  let  the  limb 
hang  down.  Originally  blue,  it  now  becomes  checkered. 
In  the  blue  parts  intensely  white  spots  appear.  After 
fifteen  minutes  the  white  spots  predominate  on  the  upper 
arm,  the  blue  spots  on  the  forearm.  In  spite  of  the 
dependent  posture  the  white  spots  do  not  lack  even  in  the 
extreme  tips  of  the  fingers.  In  my  opinion  it  does  not 
suffice  here  to  accept  merely  a  contraction  of  the  small- 
est arteries  through  the  stimulus  of  the  venous  blood, 
for  because  of  the  pronounced  whiteness  of  the  spots  the 
capillaries  too  must  have  been  participating.  Those 
interested  in  further  proofs  for  this  I  refer  to  my  repeat- 
edly cited  contribution  on  the  development  of  the  collat- 
eral circulation.  We  see,  however,  from  the  last  experi- 
ment that  arteries  and  capillaries  can  further  the  venous 
blood  by  means  of  motions  of  their  own  and  which  they 


PASSIVE   HYPEREMIA   BY   STASIS   BANDAGE  63 

do  more  or  less  in  proportion  to  the  venosity  of  the 
blood.  I  only  wish  to  remark  en  passant  that  this  prop- 
erty represents  an  extraordinary  support  of  the  circula- 
tion of  blood  in  affected  parts  of  the  body. 

Finally  the  observation  is  of  interest  that  one  can  in 
extremities  which  are  in  a  moderate  stasis  hyperemia  and 
are  at  the  same  time  rendered  venously  hyperemic,  pro- 
duce by  means  of  friction  the  most  pronounced  arterial 
hyperemia,  and  that  this  is  not  entirely  lacking  even 
in  intense  stasis.  These  observations  also  point  to  an 
independent  activity  of  the  vessels. 

The  vivid,  bright  redness  which  appears  after  loosen- 
ing the  bandage  in  intense  stasis  hyperemia,  is  identi- 
cally the  same  phenomenon  which  we  observe  as  a  so- 
called  reactive  hyperemia  after  artificial  bloodlessness 
and  which  for  a  long  time  was  accepted  as  a  pressure 
paralysis  of  the  vaso-motor  nerves.  I  have  already  con- 
vincingly proved  in  detail  that  it  means  something 
entirely  different  and  that  it  appears  after  any  desired 
interruption  or  even  limitation  of  the  arterial  flow.  This 
vivid  hyperemia  is  the  expression  of  oxygen  hunger  of 
the  bodily  parts  which  for  some  time  have  been  poorly 
or  not  at  all  fed  with  arterial  blood,  as  a  useful  process 
of  reaction.  That  it  also  occurs  after  this  grave  stasis 
hyperemia  is  proof  that  an  impoverishment  of  oxygen 
has  taken  place  in  the  constricted  limb. 

Intense  stasis,  therefore,  is  a  very  dangerous  and 
obnoxious  agent  for  the  limb  concerned.  Because  it  leads 
to  a  considerable  reduction  of  the  temperature.  I  have 
called  it  cold  stasis.  For  this  reason  I  have  never 
employed  it  in  practice.  It  is  nevertheless  possible  that 
if  employed  for  a  short  period  it  could  be  used  for  thera- 
peutic purposes.  "  That,  if  employed  for  some  time,  it 
would  be  obnoxious  and  dangerous,  needs  no  further 
explanation.  We  employ,  however,  for  a  short  time  dur- 
ing the  day  a  form  of  stasis  hyperemia,  which,  as  I  will 
later  on  describe,  stands  between  it  and  the  above 
described  moderate  stasis. 

In  the  majority  of  cases  I  have  employed  stasis  hyper- 
emia in  this  manner :  A  so-called  "cured"  or  elastic 
(woven)  rubber  bandage  is  applied  above  the  seat  of 
affection  of  a  limb  in  several  turns  firmly  enough  to 


64 


PASSIVE   HYPEREMIA   BY   STASIS   BANDAGE 


produce  the  symptoms  mentioned  in  the  beginning  of 
this  chapter  under  "moderate  stasis."  The  end  of  the 
bandage  is  fastened  with  a  safety  pin.  To  prevent  pres- 
sure from  the  bandage  it  should  be  lined  with  a  muslin 
bandage  (Scarcely  necessary  if  a  good  rubber  bandage 


'••      s. 


Fig.  5. 

is  selected. — Ed.).  For  this  same  reason  the  place  of 
bandaging  is  to  be  changed  (Fig.  5).  If  in  continued 
stasis  the  bandage  has  been  applied  in  the  morning  at  ab, 
it  is  placed  in  the  evening  at  cd  and  returned  the  follow- 
ing morning  to  ab.  Even  when  the  stasis  hyperemia  is 
used  for  a  short  time  daily  one  will  do  well  not  to  always 
select  the  same  place  for  purpose  of  constriction.  In  order 
to  prevent  blood-stasis  in  such  bodily  parts  not  in  need  of 
it,  the  part  of  the  limb  situated  peripherically  from  the 
lesion  is  best  enveloped  with  two  or  three  layers  of  a  linen 
or  flannel  bandage. 

I  have  employed  this  form  of  stasis  in  the  large 
majority  of  the  cases  I  have  treated,  continuously  with 
but  short  interruptions  or  at  least  in  the  beginning  con- 
tinuously and  later  with  prolonged  interruptions.  But 
one  must  anxiously  watch  that  the  above  described  hot 
stasis  is  maintained,  that  the  congested  limb  never  feels 
cold  to  the  touch  or  even  shows  the  vermilion  spots 
described  above.  Furtherfore,  this  form  of  stasis  must 
never  produce  inconvenience,  pain  or  hyperesthesia  in 


PASSIVE    HYPEREMIA    BY   STASIS   BANDAGE  65 

the  treated  limb.  The  patient  who  wears  the  bandage 
must  suffer  so  little  difficulty  from  it  that  while  following 
his  usual  occupation  he  forgets  its  presence.  All  the 
same  one  succeeds  in  producing  a  vigorous  hyperemia 
with  edema  especially  in  inflamed  parts  of  the  body. 

Of  late  I  have  entirely  abandoned  this  method  of  appli- 
cation in  the  treatment  of  tuberculosis,  for  it  requires 
constant  and  anxious  supervision  to  make  sure  that  hot 
stasis  is  maintained.  Furthermore,  as  I  will  discuss  later 
on,  it  undoubtedly  leads  to  changes  for  the  worse  in  this 
disease,  if  a  chronic  edema  appears,  which  is  artificially 
maintained  for  a  prolonged  period. 

I  will  here  add  another  observation  which  I  have 
made  not  infrequently  after  a  prolonged  application  of 
stasis :  If  the  remedy  is  stopped  the  previously  hyper- 
emic  limbs  are  strikingly  pale,  if  they  have  not  received 
a  yellowish  hue  due  to  small  extravasations  of  blood. 
We  see  here  the  occurrence  of  a  reaction  following  pro- 
longed and  frequently  venous  hyperemias,  similar  to  the 
one  known  to  us  for  a  long  time  as  following  arterial 
hyperemia.  As  is  well  known,  people  whose  skin  is 
much  and  frequently  rendered  hyperemic  by  heat  stimu- 
lus, such  as  bakers,  stokers,  glass-blowers,  are  very 
pale  when  away  from  their  work.  I  do  not  want  to 
attempt  to  explain  this  but  point  only  to  the  fact. 

Instead  of  the  more  or  less  lasting  stasis,  I  now  but 
employ,  at  least  in  tuberculosis,  the  interrupted  stasis 
with  variably  long  intermissions.  Generally  in  tubercu- 
losis I  do  not  allow  the  stasis  to  last  more  than  twelve 
hours  daily  and  see  to  it  that  the  developed  edema  is 
removed  until  the  reapplication  of  the  bandage.  Lately 
I  do  not  permit  the  appearance  of  a  demonstrable  edema 
at  all,  and  in  tuberculous  joints  apply  for  one  hour  daily 
a  more  vigorous  hyperemia,  the  course  of  which  follows : 
The  bandage  is  so  firmly  applied  that  a  vigorous  stasis 
hyperemia  is  produced.  The  subcutaneous  veins  swell 
strongly,  the  skin  becomes  bluish  red  and  at  about  the 
end  of  the  hour  occasionally  a  light  prickling  sensation 
appears  in  the  limb.  Real  inconvenience  or  pain,  on  the 
other  hand,  must  never  occur.  The  peripheral  part  of  the 
extremity  during  this  short  period  of  hyperemia  is  not 
enveloped.  The  process  has  the  advantage  of  great 


66 


PASSIVE   HYPEREMIA   BY   STASIS   P>ANDAGE 


simplicity  and  safety.  Even  if  one  commit  here  a  tech- 
nical error,  mischief  can  never  be  produced,  as  even 
after  an  intense  hyperemia  of  one  hour's  duration  last- 
ing injuries  do  not  occur. 

This  form  of  stasis  is  not  to  be  pushed  so  far  that  the 
above  described  vermilion  spots  occur.  As  a  rule  a 
demonstrable  edema  also  does  not  appear  during  the 
short  duration  of  the  application.  Fig.  6  illustrates  this 


method  of  stasis,  which  we  now  apply  in  tuberculosis 
and  which  I  will  later  describe  in  greater  detail.  One 
can  see  that  the  method  is  simplicity  itself.  It  is  fairly 
immaterial  where  the  stasis  bandage  is  applied  as  long 
as  it  does  not  come  too  near  the  diseased  joint.  Thus, 
for  instance,  the  bandage  can  be  applied  to  the  upper 
arm  in  disease  of  the  wrist-joint. 

In  this  method  I  usually  apply  the  stasis  bandage  as 
is  shown  in  .the  illustration,  in  such  a  way  that  its  turns 
do  not  cover  one  another,  but  surround  a  larger  part  of 


PASSIVE    HYPEREMIA   BY   STASIS    BANDAGE  67 

the  limb.     The  elastic  bandage  then  produces  no  diffi- 
culties whatever. 

I  have  so  far  been  unable  to  render  the  hip-joint 
hyperemic  by  means  of  elastic  ligation,  but  the  method 
can  be  successfully  employed  on  the  shoulder-joint,  thus, 
with  the  exception  of  the  hip-joint, -every  joint  of  the 
extremities  can  be  treated  with  this  remedy.  I  describe 
the  technic  of  stasis  of  the  shoulder-joint  (Fig  7.) : 


Fig,  7. 

Apply  loosely  around  the  neck  a  cloth  folded  like  a 
tie.  A  piece  of  thick  rubber  tubing  is  applied  from  the 
axilla  around  the  shoulder,  one  end  of  which  is  led  below 
the  tie  of  the  neckcloth,  the  other  end  outside  to  it 
and  around,  pulling  it  so  firmly  that  a  strong  venous 


68  PASSIVE  HYPEREMIA  BY  STASIS  BANDAGE 

stasis  develops  in  the  arm.  The  rubber  tubing  is  fast- 
ened above  the  cloth  with  a  pair  of  forceps,  which  at 
the  same  time  prevents  the  tubing  from  sliding  off.  To 
prevent  pressure  from  the  tubing,  a  strip  of  soft  felt  or 
cotton  is  placed  below  it  (this  is  not  shown  in  the  pic- 
ture). In  order  to  render  the  entire  shoulder-joint  hyper- 
emic,  two  strings  are  attached  to  the  front  and  rear  of 
the  tubing  and  knotted  in  the  healthy  axilla,  while  pull- 
ing firmly  (see  illustration).  In  women  it  is  practicable 
to  attach  a  ring  to  the  corset  on  the  healthy  side  and  to 
fasten  the  strings  to  it.  These  strings  are  absolutely 
essential  because  without  them  the  rubber  tubing  would 
not  grasp  enough  over  the  joint.  If  we  have  to  deal  with 
tuberculosis  of  the  shoulder-joint,  which  is  to  be  treated 
with  stasis  but  for  a  short  period  daily,  the  enveloping  of 
the  healthy  part  can  be  dispensed  with. 

Under  no  circumstances  should  the  treatment  of  the 
shoulder-joint  by  stasis  be  continued  over  twelve  hours 
daily  and  even  then  one  must  allow  intermissions  several 
times  during  the  day  because  the  tubing,  the  place  of 
which  can  of  course  not  be  changed,  would  produce 
harmful  pressure. 

Generally  stasis  hyperemia  can  be  much  easier  pro- 
duced on  the  upper  than  on  the  lower  extremities.  The 
legs  of  fat  women  occasionally  offer  difficulties.  Fre- 
quently an  insufficient  stasis  hyperemia  can  be  made 
very  vigorous  by  first  applying  the  rub'ber  bandage  so 
firmly  that  a  complete  bloodlessness  is  produced,  which 
should  be  allowed  to  remain  for  four  or  five  minutes. 
Now  the  bandage  is  loosened  enough  so  that  a  strong  re- 
action hyperemia  develops  when  the  same  bandage  is  used 
as  a  stasis  agent,  which  Iteeps  back  the  blood.  Or  the 
affected  part  can  be  painted  with  tincture  of  iodine  so 
long  until  an  intense  inflammation  of  the  skin  is  pro- 
duced. The  stasis  bandage  then  produces  a  vigorous 
hyperemia  in  the  inflamed  area. 

Naturally  blood-stasis  is  always  accompanied  by  a 
lymph-stasis.  Occasionally  one  can  now  observe  a  form 
of  stasis  which  I  have  designated  as  "white."  There  exists 
considerable  edema,  while  the  hyperemia  is  insignificant. 
The  limb,  looks  .edematous,  shining  and  white.  I  have 
explained  this  as  a  predominating  lymph-stasis.  I  can 


PASSIVE  HYPEREMIA   BY  STASIS   BANDAGE  69 

pass  this  over,  because  this  phenomenon  is  very  rare 
and  will  but  add  that  according  to  my  certainly  limited 
observations,  it  is  ineffective. 

Objections  have  been  made  to  stasis  hyperemia:  that 
especially  in  inflammations  it  is  inconvenient,  painful  and 
dangerous.  If  this  method  is  to  be  adopted  in  practice  it 
must  be  freed  from  these  reproaches.  First  of  all,  as  I  have 
already  repeatedly  done,  I  call  attention  that  any  stasis 
hyperemia  which  produces  decided  inconvenience  or  pain, 
is  false.  On  the  contrary,  we  will  yet  learn  that  the  pain- 
relieving  effect  of  this  remedy  is  one  of  its  prominent 
properties.  I  therefore  repeat :  Whoever  produces  pain 
with  stasis  hyperemia  instead  of  relief  does  not*  know 
how  to  handle  it.  Exceptionally  cases  occur  in  which,  to 
judge  from  conditions,  one  would  expect  a  favorable 
effect  from  the  remedy,  in  reality,  however,  pain  and 
trouble  are  aggravated.  We  then  have  a  case  not  suit- 
able for  this  remedy.  Another  remedy  should  be  chosen. 

The  fear  has  been  expressed  that  the  rubber  bandage 
would  produce  decubitus  at  the  place  of  application  or 
even  lead  to  gangrene  of  the  entire  constricted  part  of  the 
extremity.  The  former  I  have  observed  in  the  beginning 
when  I  made  use  of  rubber  tubing  for  the  production  of 
hyperemia.  Since  I  use  a  soft,  wide  rubber  bandage  and 
carefully  see  to  it  that  when  the  skin  on  the  place  of 
application  becomes  irritated,  an  intermission  is  made 
until  the  skin  is  healthy.  I  have  seen  no  more  decubitus. 
If  the  rules  I  have  laid  down  for  the  application  of 
stasis  hyperemia  be  followed  even  approximately, 
gangrene  of  the  extremities  subject  to  stasis  can  be 
entirely  excluded.  I  am  in  the  habit  of  advising  assist- 
ants, nurses  and  patients  that  a  stasis  bandage  remain- 
ing for  a  prolonged  while,  must  never  produce  pain  or 
paresthesia  in  the  limb,  otherwise  it  must  be  loosened 
immediately.  I  also  tell  my  assistants  that  only  the 
patient  himself  knows  whether  he  has  pain  and  that 
they  must  never  be  misled  into  replying:  "You  are 
delicate ;  you  must  stand  this ;  the  bandage  is  not  too 
firm." 

I  can  therefore  assert  that  those  dangers  are  imaginary 
and  present  only  in  the  crudest  ignorance  of  technic.  If 


70  PASSIVE   HYPEREMIA   BY  STASIS   BANDAGE 

one,  however,  uses  remedies  which  one  does  not  know 
and  control,  these  are  almost  always  dangerous. 

If  a  stasis  bandage  be  applied  to  one  place  for  a  long 
time  and  the  same  place  of  the  limb  is  chosen  for  con- 
striction, naturally  atrophy  of  the  muscle  'will  occur. 
For  this  reason  the  place  of  bandaging  should  be  fre- 
quently changed.  Nevertheless,  when  the  remedy  has 
been  employed  for  years  atrophy  can  not  altogether  be 
avoided;  it  remains,  however,  insignificant  if  the  place  of 
constriction  is  frequently  changed  and  disappears  spon- 
taneously after  the  cessation  of  the  treatment. 

I  myself  had  at  first  to  reproach  the  stasis  hyperemia 
with  the  occasional  production  of  hot  suppuration  and 
erysipelas  in  "open"  tuberculosis.  I  reported  several  bad 
cases  of  this  sort.  I  can  now  assure  that  they  all  were  the 
result  of  a  then  wrongly  employed  technic.  I  then  made 
use  of  a  too  vigorous  stasis  hyperemia,  which  led  to 
chronic  edema.  As  we  know  from  experience,  the 
latter  favor  the  occurrence  of  acute  inflammation.  Mean- 
while, we  have  developed  the  technic  of  stasis  hyperemia 
for  inflammatory  affections  to  such  a  degree  that  this  dan- 
ger is  entirely  avoided.  On  the  contrary,  I  will  yet  dem- 
onstrate that  the  method  of  stasis  practiced  by  us  favor- 
ably influences  the  course  of  many  acute  inflammations, 
even  that  of  erysipelas.  Thus,  since  my  detailed  contribu- 
tion on  this  danger  in  1894  I  have  observed  but  once 
the  addition  of  an  acute  inflammation  to  an  open  tuber- 
culosis which  was  due  to  the  treatment,  and  this  only 
lately,  when  we  again  were  occupied  with  the  introduc- 
tion of  a  new  technic  (suction  apparatus  for  the  produc- 
tion of  hyperemia  in  tuberculosis)  and  had  to  learn  from 
failures.  I  will  relate  this  case  in  the  course  of  this  work. 

Things  are  similar  with  the  other  unfavorable  observa- 
tion made  by  me,  the  appearance  of  stasis  ulcers  under 
the  influence  of  hyperemia.  These,  too,  are  due  to  faulty 
technic. 

I  am  therefore  pleased  to  be  able  to  assure  that  the 
only  danger  from  stasis  hyperemia,  which  I  at  first  had 
to  recognize  as  existing,  and  which  I  myself  was  the  first 
to  observe  and  report,  was  purely  due  to  an  error  of 
technic  which  can  be  easily  avoided. 

Though  I  have  employed  stasis  hyperemia  for  months 


PASSIVE   HYPEREMIA  BY  STASIS  BANDAGE  71 

and  year.-,  T  have  never  seen  the  occurrence  of  varix  peri- 
pherically  from  the  place  of  constriction.  This  is  the  best 
proof  for  the  view  already  expressed  elsewhere  that 
varix  is  not  due  to  stasis  alone,  but  that  there  must 
exist  in  addition  an  affection  of  the  wall  of  the  vein. 

To  this  may  be  added  the  observation  described  in  the 
first  part  of  this  chapter  that  the  subcutaneous  veins 
which  have  at  first  become  tightly  stretched  by  the 
stasis  bandage,  after  a  few  hours  begin  to  contract  so 
that  they  scarcely  appear  dilated. 

Theoretically  considered,  one  would  easily  imagine  that 
prolonged  stasis  hyperemia  embracing  larger  areas  of  the 
body  would  produce  a  decomposition  of  blood,  which 
may  lead  to  undesirable  consequences,  for  in  stasis  hyper- 
emia numerous  red  blood  discs  which  exude  into  the 
tissues  and  perhaps  such  in  the  vessels  themselves  perish 
while  important  chemical  changes  take  place  in  the 
stased  blood. 

Landois  (46)  says  in  his  text-book  of  physiology  that 
the  red  blood  discs  of  carbonic  acid  blood  dissolve  the 
easiest,  but  remarks  in  his  Transfusion  of  Blood  (47)  that 
while  carbonic  acid  blood  dissolves  easily,  the  objection 
that  the  blood  containing  carbonic  acid  was  perhaps 
already  in  partial  dissolution  is  to  be  decidedly  rejected, 
for  if  carbonic  acid  blood  of  animals  is  arterialized  it 
again  becomes  less  soluble. 

E.  Grawitz  (48)  mentions  that  in  highly  concentrated 
stasis  blood  in  heart  troubles,  while  there  is  a  disturb- 
ance of  compensation  the  hemoglobin  is  loosely  attached 
to  the  stroma  and  thinks  it  probable  that  in  such  cases  a 
greater  decomposition  of  the  red  blood  corpuscles  takes 
place  in  the  liver. 

Chvostek  (49)  found  the  serum  of  stasis  blood  taken 
from  a  constricted  finger — which,  however,  lasted  but 
ten  minutes — free  from  hemoglobin. 

That  in  stasis  hyperemia,  which  we  make  use  of  for 
therapeutic  purposes,  decomposition  of  blood  frequently 
does  take  place,  is  proved  by  the  slight  yellowish  color 
of  the  skin  which  appears  after  a  prolonged  application 
of  the  remedy. 

This  frequently  is  not  lacking  even  when  the  stasis 
has  been  employed  for  a  short  period  daily  and  in  a 


72  PASSIVE   HYPEREMIA  BY  STASIS   BANDAGE 

moderate  degree,  occurring  especially  in  inflamed  parts 
of  the  body.  As  we  generally  maintain  more  prolonged 
and  more  intense  stases  than  those  had  in  view  by  the 
above-mentioned  experimenters,  it  is  doubtful  whether 
we  occasionally  do  produce  greater  decomposition  of 
blood.  If  this,  however,  were  so,  w.e  should  be  able 
to  easily  demonstrate  them ;  for  we  know  from  expe- 
rience, gained  from  transfusion  of  foreign  blood  and 
from  a  series  of  diseases,  characterized  by  immense 
decomposition  of  the  blood,  that  in  such  cases  liver 
and  spleen  are  not  sufficient  to  take  up  the  decompose  1 
blood,  but  that  albumin  and  in  pronounced  decomposition 
also  hemoglobin,  appear  in  the  urine.  Furthermore, 
these  cases  have  fever,  which  as  a  rule  starts  with  ;i 
chill. 

Among  the  large  number  of  cases  which  we  have 
treated  with  stasis  hyperemia,  we  have  but  once  ob- 
served such  a  thing.  It.  was  a  weak,  small  boy,  who 
always  showed  high  fever  and  albuminuria  whenever 
treated  with  the  stasis  bandage  applied  to  the  thigh, 
though  his  general  condition  remained  undisturbed. 
Both  symptoms  appeared  soon  after  the  application  of  the 
bandage  and  quickly  disappeared  as  soon  as  it  was  re- 
moved. Besides,  these  phenomena  have  not  done  him 
the  least  harm.  Probably  in  this  case  we  had  to  deal 
\\ith  a  weakness  of  the  red  blood  discs,  or  perhaps  also 
other  components  of  blood  as  it  occurs  in  that  puz/.lin;; 
disease  known  as  paroxysmal  hemoglobinuria,  in  which 
the  slightest  external  causes,  especially  cold,  produce 
pronounced  blood  decomposition,  which  may  follow  a 
course  resembling  malaria.  As  is  well  known,  albumin 
and  hemoglobin  have  been  found  transitorily  in  the  urine 
after  cold  baths  (50). 

Reineboth  (51)  and  Reineboth  and  Kohlljardt  (52) 
found  that  in  rabbits  after  chilling  (immersion  in  ice- 
water  for  five  minutes)  hemoglobin  is  given  off  to  the 
serum  without  it  passing  into  the  urine.  It  is  said  to 
be  taken  care  of  in  the  liver  and  spleen.  The  correct- 
ness of  these  experiments  is  disputed  by  E.  Grawitz  (53). 

The  following  experiment,  which  I  have  made  on 
myself  for  several  consecutive  days  with  the  same  result, 
would  seem  to  prove  that  generally  an  extensive  stasis 


PASSIVE   HYPEREMIA   BY   STASIS   BANDAGE  73 

hypcrcmia  would  not  produce  so  decided  a  decomposi- 
tion of  blood  as  to  make  it  a  matter  of  importance,  demon- 
strable by  fever,  hemoglobin  and  albumin  in  the  urine: 
I  applied  high  on  both  thighs  a  stasis  bandage  so  firmly 
that  the  above-described  intense  stasis  hyperemia  was 
produced,  i.  e.,  the  superficial  veins  became  prominent, 
the  limbs  bluish  red,  swollen,  showing  vermilion  spots. 
I  succeed  in  this  on  myself  excellently.  After  a  short 
lime  a  sensation  of  pricking,  numbness  and  fatigue  in 
the  legs  occurs,  and  finally  pain,  so  that  it  requires  the 
exertion  of  a  maximum  of  will-power  to  stand  the  ex- 
tensive stasis  more  than  one-half  hour.  In  addition, 
phenomena  plainly  show  that  much  blood  is  taken  from 
the  rest  of  the  body;  the  pulse  becomes  small,  increases 
from  68  to  88 ;  respiration  is  deeper,  there  is  a  sensa- 
tion of  lack  of  blood  in  the  head  and  inability  to  think. 
After  forty-five  minutes  the  stasis  bandages  are  loosened 
and  all  the  phenomena  immediately  disappear.  On  the 
skin  can  be  seen  the  above-described  carmine  red  hemor- 
rhagic  points.  I  could  never  demonstrate  after  these  ex- 
periments albumin  or  hemoglobin  in  my  urine  nor  a 
regular  influence  on  the  temperature.  My  general  condi- 
tion was  never  disturbed  by  this  enormous  hyperemia 
(which  certainly  would  never  be  employed  for  therapeu- 
tic purposes),  although  I  repeated  the  experiment  for 
five  consecutive  days.' 

Nevertheless,  there  possibly  was  a  destruction  of  red 
blood  discs.  But  a  not  too  extensive  decomposition  of 
these  does  not  lead  to  the  appearance  of  either  hemo- 
globin or  albumin  in  the  urine,  and  in  this  my  experience 
with  transfusion  of  foreign  blood  agrees  with  Reineboth 
and  Kohlhardt. 


CHAPTER  VIII 

HYPEREMIA  BY  SUCTION  APPARATUS 

The  most  magnificent  and  extensive  hyperemia  can  be 
produced  in  the  extremities  by  means  of  Junod's  boot, 
or  apparatus  constructed  on  the  same  principle.  Junod's 
large  cupping  glasses  and  cupping  boots  in  their  time 
produced  quite  a  sensation  in  the  medical  world,  but 
have  been  forgotten,  so  that  undoubtedly  the  majority 
of  physicians  have  no  knowledge  of  their  existence.  I 
de-em  it  therefore  advisable  to  describe  somewhat  fully 
these  apparatus,  which,  in  my  opinion,  will  again  play 
a  role  in  medicine,  though  in  a  different  way  than 
their  inventor  and  his  imitators  intended.  Junod  (54) 
presented  to  the  French  Academy  of  Sciences,  in  1834. 
his  experience  and  experiments  with  the  application  of 
thinned  and  thickened  air  to  the  entire  body  or  to  single 
portions  of  it.  In  1838  he  (55)  described  in  a  new 
essay  improvements  on  his  apparatus,  and  in  1841  he 
made  a  report  to  the  Academy,  consisting  in  the  narra- 
tion of  several  cases  treated  with  his  apparatus  (56). 
Others  made  extensive  use  of  Junod's  apparatus  and  soon 
several  contributions  on  their  efficacy  were  published, 
among  which  Ficinus'  (57)  "The  Hemospasia"  is  the 
most  exhaustive  and  detailed.  In  the  following  description 
I  will  therefore  principally  follow  the  statements  of  that 
physician. 

Inasmuch  as  the  large  apparatus  of  Junod,  which  act 
on  the  entire  body,  and  the  appliances  intended  for  the 
limbs,  which  force  compressed  air  into  the  boots,  are  of 
little  interest  to  us,  I  will  limit  myself  to  the  descrip- 
tion of  the  suction  apparatus — the  earlier  well-known 
"Junod's  boot." 

At  first  Junod  prepared  four  glass  and  copper  cylinders 
for  the  four  extremities.  To  insure  an  air-tight  fit  to  the 
variable  thickness  of  the  limbs  the  open  end  of  each  cylin- 
der had  four  attachments  of  variable  width  and  form. 
Besides  this  a  broad  rubber  ring,  fastened  to  the  attach- 
ment and  which  was  fastened  with  a  bandage  to  the 
extremity,  served  to  shut  the  air.  The  cylinders  intended 
for  the  lower  extremities  had  the  form  of  a  boot.  They 

74 


HYPEREMIA  BY  SUCTION   APPARATUS  75 

were  supplied  with  a  manometer  and  a  thermometer. 
The  latter  served  to  measure  the  temperature  of  warm 
vapors,  which  Junod  occasionally  made  to  enter  his 
apparatus  in  order  to  produce  a  more  intense  hyper- 
emia.  The  air  in  the  interior  of  the  apparatus  was 
thinned  by  means  of  a  small  suction  syringe. 

Junod  has  briefly  described  the  effect  of  his  apparatus 
as  follows:  "If  the  atmospheric  pressure  over  the  ex- 
tremities is  diminished,  the  skin  swells  and  becomes  red 
and  the  limb  soon  increases  in  circumference.  The 
inflowing-  blood  spreads  an  unaccustomed  warmth  hi  it, 
the  excreted  moisture  quickly  evaporates  and  deposits  on 
the  walls  of  the  cylinder.  This  operation  leaves  behind 
for  a  short  while  a  sensation  of  stiffness  and  numbness, 
which  soon  passes  away.  If  warm  vapors  are  employed 
at  the  same  time  the  effect  of  the  thinning  of  the  air  is 
still  more  pronounced.  Among  general  phenomena 
are  observed  a  sensation  of  ease  in  the  head,  the  face 
pales,  the  pulse  of  the  temporal  artery  becomes  slower, 
small  and  disappears  perhaps  entirely.  There  is  an  in- 
clination to  faint.  At  the  same  time  respiration  becomes 
shallow,  the  activity  of  the  intestines  is  diminished  and 
nausea  develops.  Finally  perspiration  covers  the  entire 
skin." 

The  description  of  these  general  phenomena  shows 
that  Junod  made  energetic  use  of  his  apparatus  so  that 
a  good  deal  of  blood  was  taken  from  the  circulation. 

Later  Junod  described  some  improvements  on  his 
apparatus,  which  essentially  relate  to  the  convenient  and 
perfect  air-tight  closure.  He  discarded  the  four  attach- 
ment pieces  and  fastened  instead  to  the  open  end  of  the 
apparatus  strips  of  strong  cotton  material  which  in 
changeable  numbers  turned  inwards  enabled  the  fitting 
of  the  apparatus  to  the  limb ;  over  this  was  fastened 
a  cuff  of  caoutchouc,  which  was  pulled  over  the  limb, 
hermetically  attaching  itself  to  it  when  the  air  in  the 
apparatus  was  thinned. 

In  1843  Junod  (58)  again  published  an  essay  which 
treats  on  the  value  of  hemospasia  (the  name  hemospasia, 
according  to  Ficinus,  was  introduced  by  Bonnard — 
aifia,  blood,  and  ffirdw,  suck).  He  asserts  that  deriva- 
tive and  revulsive  therapy  has  reached  an  undreamed 


76  HYPEREMIA  BY  SUCTION  APPARATUS 

efficacy  on  account  of  his  apparatus.  There  is  scarcely 
a  disease  against  which  he  does  not  consider  hemospasia 
indicated  and  useful. 

Junod  had  already  spoken  of  the  value  of  fainting, 
which  could  be  produced  with  his  apparatus  by  drawing 
the  blood  into  the  extremities.  He  states  that  he  has 
been  consulted  by  surgeons  to  artificially  produce  syn- 
cope. During  this  syncope  operations  could  be  per- 
formed painlessly,  while  dislocations  could  be  easily 
reduced  because  of  the  relaxation  of  the  muscles.  He 
also  believed  that  an  artificial  syncope  in  certain 
diseases  could  be  advantageous. 

Naturally  the  external  air  pressure,  while  the  air 
within  the  apparatus  is  thinned,  permits  it  to  wander  up 
along  the  extremity  or  to  draw  it  in  more  firmly.  To 
prevent  this  Junod  put  in  the  interior  of  his  apparatus 
partitions  and  belts,  against  which  the  hand  or  foot  could 
press  for  support. 

It  is  worthy  of  mention  that  Junod  repeatedly  empha- 
sizes that  his  apparatus  are  entirely  harmless  and  states 
that  his  boot  can  be  utilized  even  in  varicose  veins,  for 
the  apparatus  dilates  only  the  capillaries ;  the  veins  of 
the  skin  do  not  dilate  after  the  removal  of  the  apparatus, 
but  contract. 

Junod's  apparatus  were  soon  employed  by  many  and" 
recommended.  In  1838  Erpenbeck  (59)  described  an 
apparatus  almost  identical  with  Junod's  boot.  This 
was  constructed  of  tin ;  the  endings  were  produced  by 
lined  leather  cuffs  or  by  different  large  neck  parts,  which 
could  be  slipped  over  the  apparatus.  This  apparatus  does 
not  offer  anything  essentially  new.  Erpenbeck,  too,  re- 
gards it  simply  as  a  revulsive  and  derivation  agent.  He 
is  silent  of  the  fact  that  Junod  has  already  employed 
the  same  apparatus  for  the  same  purposes.  In  a  second 
contribution  (60),  he  describes  the  experience  he  has 
gained  with  his  apparatus  and  informs  us  of  an  im- 
provement on  it  that  he  establishes  an  air-tight  closure 
by  fastening  an  ox-bladder  which  he  ties  to  the  leg  and 
the  apparatus.  Furthermore,  he  gives  an  adventurous 
description  of  how  he  imagines  the  reduction  of  a  dis- 
located thigh  with  his  apparatus. 

The  air  is  rarified  by  suction  with  the  mouth.     Erpen- 


HYPEREMIA  BY  SUCTION   APPARATUS  77 

beck  asserts  to  have  observed  all  the  phenomena  as 
given  in  Junod's  description,  including  the  pallor  oj  the 
face  and  the  syncope. 

Ficinus  introduced  some  modifications  of  Junod's  ap- 
paratus. '  On  account  of  the  lessened  expense,  he  made 
his  apparatus,  like  Erpenbeck,  from  tin  and  utilized  a 
long  rubber  cuff,  for  the  end  which  he  fastened  to  the  leg 
by  means  of  cured  rubber  bandage.  The  other  changes 
concern  the  suction  pump  and  manometer.  As  we  are 
not  in  need  of  a  manometer  and  as  we  make  use  of  a 
new  and  far  better  pump,  we  can  pass  them  over.  It 
can  be  said  of  Ficinus'  apparatus,  too,  that  they  hardly 
represent  an  improvement  over  those  of  Junod. 

In  accordance  with  the  views  then  held,  Junod's  appa- 
ratus and  their  imitations  were  used  solely  as  revulsiva 
and  derivantia ;  that  is  to  say,  it  was  attempted  to 
send  the  alleged  accumulation  of  blood  in  diseased 
places  toward  healthy  parts.  Magendie,  the  reporter  of 
the  French  academy  on  Junod's  apparatus,  maintains 
that  every  physician  must  value  this  invention  as  a 
great  boon,  as  it  enables  us  to  combat  the  congestion 
of  blood  toward  noble  parts  or  its  transpudation  into 
the  tissues"  by  deviating  it  toward  the  extremities  with- 
out lastingly  withdrawing  the  blood  from  the  body. 
Junod  himself  has  given  this  as  the  purpose  of  his 
apparatus  and  all  those  who  used  them  started  from  these 
same  views. 

There  was  no  shyness  shown  in  the  utilization  of  the 
apparatus,  which,  according  to  the  description,  were 
employed  in  the  most  energetic  manner.  This  could  be 
risked  because  the  blood  was  drawn  toward  healthy 
parts.  Junod  himself  mentions  only  reddening  of  the 
skin  and  swelling  of  the  limb  which  is  treated  in  his 
apparatus,  but  admits  that  this  swelling,  which  feels 
firm  and  hard,  remains.  The  illustrations  given  by  him 
and  Ficinus  of  limbs  so  treated  prove  that  the  swell- 
ings were  indeed  considerable.  The  swelling  remains  for 
several  days  and  disappears  gradually,  while  the  skin  of 
the  limb  assumes  a  greenish  yellow  and  green  color ;  that 
is  to  say,  the  apparatus  has  been  so  forcibly  employed 
that  it  leads  to  extensive  hemorrhages.  .  It  is  further 
described  that  there  appeared  numerous  point-like 


HYPEREMIA  BY  SUCTION  APPARATUS 


hemorrhages;  especially  at  the  hair,  and  red,  hltie  and 
yellow  streaks  in  the  skin. 

From  the  following  contributions,  too,  is  evident  how 
far  hemospasic  was  pushed :  Ficinus  says  that  in  his 
apparatus  "the  foot  is  forcibly  pressed  against  the  bot- 


H ./ 


Fie.  8. 


torn,  to  which  it  appears  like  glued.  Some  fear  the 
leg  might  become  fractured  under  the  burden  of  the 
atmosphere."  As  other  consequences,  he  cites  a  sensa- 


HYPEREMIA   BY  SUCTION   APPARATUS  70 

tion  of  numbness,  pricking  and  lancinating  sensations, 
vigorous  tension  of  the  skin,  especially  in  the  upper 
part  of  the  limb  within  the  boot.  If  it  is  an  arm,  a  sensa- 
tion of  weakness  and  exhaustion  in  the  muscles  remains 
even  during  the  following  day.  Once  he  observed  in  a 
large  toe  a  sensation  as  if  it  had  sustained  a  contusion  for 
fourteen  days.  The  thinning  of  air  which  was  necessary 
to  produce  such  an  effect  was  one-seventh  to  one-third 
of  an  atmosphere. 

I  have  imitated  Junod's  apparatus  so  modified  as  to 
produce  hyperemia  in  diseased  parts.  For  such  a  pur- 
pose it  is  evident  that  the  above-described  effect  must 
never  result.  We  desire  to  produce  hyperemia  only, 
not  hemorrhages ;  we  want  to  succeed  in  getting  a 
swelling  of  the  affected  parts,  which  should  disappear 
soon  after  removal  of  the.  apparatus  and  not  remain  for 
days.  I  will  first  of  all  give  a  description  of  the  appa- 
ratus now  used  by  me. 

I  make  now  use  of  glass  apparatus  exclusively.  They 
have  the  advantage  of  enabling  one  to  observe  the 
color  and  swelling  of  the  limbs,  aside  from  the  fact  that 
they  are  cheap  and  easily  cleansed.  I  use  three  sizes  of 
glass  apparatus.  The  smallest  size  is  for  thin  arms  (Fig. 
8),  the  next  is  for  thick  arms  and  legs  of  children,  the 
third  for  the  legs  of  adults.  The  upper  end  of  the  appa- 
ratus terminates  into  a  narrow  neck,  the  width  of 
which  corresponds  to  whatever  purpose  it  is  for  and  by 
which  attachment  to  the  extremity  is  made  easy.  In 
order  to  make  the  attachment  air-tight,  a  cuff  of  good 
Para  rubber  is  fastened  to  the  neck.  A  book-binder  is 
ordered  to  glue  it  to  the  glass,  around  which  is  wound 
twine  which  also  is  glued  on. 

After  the  limb  is  placed  in  the  apparatus,  the  cuff 
is  wound  to  the  extremity  by  means  of  a  rubber  bandage, 
but  not  firmly  enough  to  produce  a  decided  hyperemia 
of  the  limb  within  the  apparatus.  One  can  easily  learn 
to  obtain  an  air-tight  seclusion  without  producing  at 
the  same  time  hyperemia. 

Next  the  air  within  the  apparatus  is  thinned  by  means 
of  a  suction  pump.  One  can  make  use  for  this  of  the 
small  pump  designed  by  Junod  but  I  prefer  the  larger 
pump  used  by  bicycle  dealers  for  the  inflation  of  tires 


80  HYPEREMIA   BY  SUCTION   APPARATUS 

save  that  the  position  of  the  valves  is  changed  so  that 
the  pressure'  pump  is  converted  into  a  suction  pump 
(Fig.  8). 

As  can  be  seen  in  the^  illustration,  the  pump 'is  con- 
nected with  the  apparatus  by  means  of  rubber  tubing. 
The  connection  is  made  with  a  rubber  stopper  which 
fits  hermetically  into  the  opening  of  the  apparatus.  The 
stopper  is  bored  through  by  a  stop-cock  which  can  be 
opened  and  closed  at  will. 

The  treatment  of  the  affected  limb  is  carried  out  as 
follows:  The  air  is  thinned  to  a  degree  which  can  be 
borne  by  the  patient  without  complaint.  Besides,  the 
intensity  of  the  obtained  hyperemia  is  observed  through 
the  glass.  If  the  desired  intensity  has  been  obtained  it 
is  kept  up  for  several  minutes  by  closing  the  stop-cock, 
or,  should  this  not  be  air-tight,  by  pumping  slowly. 
Then  the  rubber  stopper  is  removed,  which  permits  the 
egress  of  air,  and  after  an  interval  of  from  twenty  sec- 
onds to  one  minute,  the  thinning  of  the  air  is  again 
undertaken  and  hyperemia  produced. 

On  account  of  the  external  air-pressure  the  Para  rubber 
cuff  is  forced  into  the  apparatus  like  a  blown  sail  and 
at  the  same  time  the  extremity  is  strongly  forced  into  the 
cylinder.  As  we  do  not  desire  the  pressure  of  the 
affected  limbs  against  the  walls  of  the  apparatus,  the 
patient  must  attempt  to  pull  out  the  limb  while  holding 
fast  to  the  apparatus. 

I  make  use  of  the  apparatus  described  for  the  legs  and 
arms  up  to  the  hip  and  shoulder-joint  respectively.  For 
these  two  joints  we  have  so  far  not  succeeded  in  making 
suitable  suction  apparatus.  However,  it  is  possible  that 
the  difficulties  will  be  overcome  yet.  Each  part,  from 
the  middle  of  the  thigh  and  upper  arm  to  the  ends  of  the 
toes  and  fingers,  can  be  rendered  hyperemic  in  these 
cylinders.  To  be  sure,  the  entire  leg  and  foot  are  ren- 
dered hyperemic  when,  for  instance,  it  is  intended  to 
treat  the  knee-joint  only,  but  as  the  hyperemia  is  not 
very  intense  and  of  but  short  duration,  this  does  no 
harm  ;  syncope  or  other  disagreeable  phenomena  are  not 
produced  by  it.  If  one  desires  to  limit  the  hyperemia 
the  peripheral  portion  of  the  extremity  should  be  tightly 
bandaged.  In  such  cases,  however,  the  thinning  of  the 


HYPEREMIA   BY   SUCTION    APPARATUS 


81 


air  must  never  be  sufficient  to  produce  a  cutting  of  the 
margin  of  the  bandage  in  the  skin,  thus  producing  effu- 
sion of  blood.  This  pronounced  rarefication  of  air  need 
not  be  considered,  as  it  is  of  no  purpose  in  our  work ; 
besides,  the  bandaging  of  the  extremity  is  indicated  but 
very  rarely. 

For  the  purpose  of  rendering  hyperemic  limited  por- 
tions of  an  extremity,  I  have  constructed  glass  cylinders 
open  at  both  ends,  which  are  provided  with  Para  rubber 
cuffs.  Such  an  apparatus  for  the  knee  is  depicted  in 


Fig.  9. 

Fig.  9,  which  needs  no  further  description.  (In  the  illus- 
tration only  the  upper  cuff  is  shown  fastened  by  a 
rubber  bandage.  The  lower  one  is  left  loose  in  order  to 
better  illustrate  it.) 

On  account  of  the  thinning  of  the  air,  which  forces  the 
limb  into  the  cylinder  from  above  and  below,  the  joints 
become  curved  in  the  apparatus. 

In  a  similar  manner  suction  apparatus  can  be  con- 
structed for  any  part  of  the  limbs  below  the  hip  and 
shoulder  joints.  On  the  whole,  however,  they  can  be 
dispensed  with,  because  they  are  too  complicated  and  be- 
cause the  double  attachment  makes  an  air-tight  exclusion 
more  difficult  to  obtain.  We  have  ceased  to  use  rubber 
cuffs  because  they  do  not  adhere  to  the  limb  as  well  as 
those  made  of  the  pliant  Para  rubber  material. 


82  HYPEREMIA   BY  SUCTION   APPARATUS 

The  changes  taking  place  in  the  treated  part  can  be 
nicely  observed  through  the  glass.  As  a  rule,  the  in- 
tense forms  of  hyperemia  are  not  obtained  in  the  first 
few  seances  which  appear  without  difficulty  after  re- 
peated applications. 

If  the  bandage  around  the  cuff  is  not  wound  so  tight 
as  to  itself  produce  a  hyperemia,  the  limb  placed  in  the 
apparatus  has  a  normal  color  previous  to  the  thinning  of 
the  air.  After  a  few  pumps  it  swells  a  little  and  reddens 
vividly.  Frequently  each  suction  produces  a  moist  fog 
which  emanates  from  the  limb,  which  is  absent  in  -some 
instances.  As  a  rule,  a  moisture  forms  on  the  inner 
walls  of  the  apparatus  and  occasionally  becomes  so  dense 
that  the  glass  is  rendered  opaque,  so  that  the  treated  limb 
can  not  be  observed. 

On  continuing  the  thinning  of  the  air,  blue  streaks 
appear  in  the  red  skin  or  the  entire  skin  assumes  a  bluish 
hue  interspersed  with  numerous  vermilion  spots,  similar 
to  those  with  which  we  have  become  acquainted  in 
connection  with  intense  stasis  hyperemia. 

The  oftener  the  apparatus  is  used  the  more  magnifi- 
cent becomes  the  hyperemia.  It  appears  in  an  intense 
form  in  tuberculous  extremities,  which  sometimes 
assume  entirely  different  forms  on  account  of  circum- 
scribed swellings.  The  increase  in  the  volume  of  the 
extremities  can  become  so  pronounced  that  they  can  be 
removed  only  by  the  use  of  great  force  from  the  narrow 
neck  of  the  apparatus  into  which  they  have  been 
squeezed  by  the  external  air  pressure.  If  the  air  was 
considerably  thinned  the  hair  follicles  are  sucked  out,  so 
that  the  limb  appears  with  a  "goose-skin."  The  effect 
of  the  thinned  air  on  open  ulcers  and  fistulse  will  be 
discussed  later  in  connection  with  the  use  of  the  appa- 
ratus in  tuberculosis. 

Even  in  normal  skin,  extreme  thinning  of  the  air  pro- 
duces point-like  hemorrhages  and  numerous  vermilion 
spots.  The  patient  states  that  the  skin  feels  tense,  some- 
times so  much  so  'that  he  is  afraid  the  skin  may  burst. 
In  the  limb  appears  a  sensation  of  pricking  "as  if  one 
were  treated  with  electricity."  When  the  thinning  is 
pronounced  the  joints,  particularly  the  wrist,  begin  to 


HYPEREMIA   BY   SUCTION   APPARATUS  83 

pain  and  one  has  a  sensation  as  if  the  ends  of  the  joints 
were  separated  by  a  strong  pull. 

A  sensation  of  warmth  develops  in  the  hyperemic 
limb,  which  remains  for  hours  after  the  treatment.  Ob- 
jectively an  elevation  of  the  surface  temperature  can  be 
demonstrated.  As  an  example,  an  ankylosed  knee-joint 
showed  an  increase  of  2°  C.  nine  hours  after  removal 
from  the  apparatus. 

Patients  suffering  from  chronic  rheumatism  state  that 
the  affected  joints  which  heretofore  were  cold  to  the 
feel,  became  warm  after  treatment  and  remained  so  dur- 
ing the  intervals.  Considerable  increase  of  surface  tem- 
perature can  be  observed,  especially  in  t  iberculous  joints 
subjected  to  the  treatment.  One  can  therefore  see  that 
the  dilatation  of  the  vessels  has  a  prolonged  effect. 

As  already  said,  the  most  intense  forms  of  hyperemia 
must  never  be'  produced  on  our  extremities  with  the 
suction  apparatus,  because  we  would  injure  rather  than 
do  good.  The  appearance  of  hemorrhages  in  the  tissues 
and  of  too  many  vermilion  spots  must  be  avoided,  as  they 
are  the  sign  of  a  decided  disturbance  of  circulation.  A 
few  spots,  however,  can  not  be  avoided  in  effective 
applications  of  the  apparatus. 

It  is  important  to  decide  which  form  of  hyperemia 
is  produced  by  these  suction  apparatus.  Without  doubt 
the  thinned  air  first  of  all  affects  the  capillaries,  because 
their  walls  are  the  most  yielding,  and  then  the  veins. 
The  strong  elastic  walls  of  the  arteries  in  all  probability 
are  but  little  influenced.  If  we  accept  this  as  correct,  we 
shcfuld  surmise  at  first  glance  that  a  dilatation  of  the 
current  bed  while  the  inflow  remains  the  same  produces 
a  diminution  of  the  current.  I  have  demonstrated  in 
my  above-mentioned  contribution  on  the  collateral  circu- 
lation that  this  apparently  clear  conclusion  from  a  phys- 
ical standpoint  is  a  false  conclusion  when  considered 
in  connection  with  the  conditions  of  the  living  body. 
Experience  shows  that  a  dilatation  of  a  certain  area  of 
capillaries  is,  on  the  contrary,  associated  with  an  ac- 
celeration of  the  blood-current  in  the  concerned  area. 
The  diminution  of  the  resistance  to  the  blood  circulation 
which  is  following  the  dilatation  is  so  enormous  that  the 
diminishing  effect  of  the  dilated  bed  need  "not  even  be 


84  HYPEREMIA  BY  SUCTION  APPARATUS 

considered.  Generally  we  can  say,  local  dilatation  of  a 
certain  capillary  area,  provided  the  heart  action  remains 
the  same,  is  associated  with  a  considerable  acceleration 
of  the  blood-current — a  fact,  by  the  way,  which  over- 
throws a  whole  series  of  speculations  theoretically  built 
up  by  some  hydrotherapists. 

Nevertheless  there  is  no  doubt  that  t'he  suction  appa- 
ratus used  in  the  above-described  mild  way  in  the  major- 
ity of  instances  produces  stasis  hyperemia,  as  can  be 
seen  from  the  description.  The  reason  for  this  is  found 
in  the  hindrance  of  the  venous  return  flow.  As  soon  as 
the  air  in  the  interior  of  the  apparatus  is  thinned,  the 
external  atmospheric  pressure  forces  the  cuff  against 
the  limb.  This  is  still  more  increased  because  the  cuff 
is  fastened  with  a  rubber  bandage.  Both  act  then  as 
a  stasis  bandage.  From  the  description  which  we  have 
given  of  Junod's  apparatus  it  is  evident  that  the  older 
physicians  produced  with  the  suction  the  most  pro- 
nounced stasis  hyperemia. 

The  following  experiment  made  on  myself,  however, 
proves  that  with  the  same  apparatus  in  certain  degrees 
of  thinning  of  the  air,  in  consequence  of  the  diminution 
of  resistance  in  the  capillaries,  undoubted  arterial  hyper- 
emia can  be  produced :  I  place  my  arm  in  a  glass  suction 
apparatus  and  fasten  the  cuff  with  a  rubber  bandage. 
It  appears  that  from  it  alone  a*  slight  stasis  hyperemia 
appears  in  the  limb.  On  intense  thinning  of  the  air 
appears  a  dark  hyperemia  of  the  skin,  the  superficial 
veins  swell  and  a  pricking  sensation  occurs  in  the 
extremity.  Gradually  in  the  darkened  skin  the  well- 
known  vermilion  spots  of  stasis  hyperemia  appear  here 
too.  All  these  phenomena  become  more  pronounced  as 
the  thinning  of  the  air  is  increased.  The  extremity  in- 
creases in  size  and  "sweats"  considerably.  The  impres- 
sion prevails  that  the  blood  has  stagnated  in  the  swollen 
extremity.  That  this  is  really  so  is  proved  by  the 
decided  reaction  hyperemia — arterial — of  the  limb  which 
appears  twenty  minutes  after  removal  from  the  appa- 
ratus. For  this  reaction  hyperemia  is  the  best  measure 
for  the  impoverishment  in  oxygen  by  its  duration  and 
intensity  as  I  have  described  it  in  detail  in  former  con- 
tributions. 


HYPEREMIA  BY  SUCTION  APPARATUS  85 

1  now  place  the  arterially  reddened  arm  in  the  appa- 
ratus, apply  the  bandage  less  tight  and  thin  the  air  but 
little.  An  enormous  bright  red  hyperemia  appears  and 
I  experience  in  the  limb  a  sensation  of  intense  warmth. 
The  arm  "sweats"  considerably,  so  that  the  walls  of  the 
apparatus  become  moist,  \vhile  one  feels  as  if  the  limb 
\\as  in  a  moist,  warm  atmosphere.  The  evidently  in- 
tense arterial  hyperemia  can  be  comfortably  maintained 
for  twenty  minutes,  when  the  experiment  is  terminated. 

Because  one  can  produce  with  the  suction  apparatus 
active  and  passive  hyperemia,  I  have  designated  the 
hyperemia  produced  by  it  "mixed."  The  expression,  I 
admit,  is  not  a  happy  one. 

These  apparatus  are  indicated  in  all  affections  which 
are  suitable  for  treatment  with  hyperemia,  but  I  have 
not  risked  their  use  in  acute  inflammations.  In  the 
clinical  part  of  this  book,  I  will  describe  their  use  in  the 
individual  affections.  They  are  extraordinarily  conve- 
nient and  there  should  be  a  demand  for  them.  Cer- 
tainly I  admit  that  they  can  be  considerably  improved. 


CHAPTER  IX 

HYPEREMIA  BY  DRY  CUPPING 

The  dry  cupping  glass  can  well  be  employed  for  the 
purpose  of  rendering  hyperemic  superficially  situated 
lesions.  The  air  within  the  glass  may  be  rarefied  either 
by  igniting  a  little  alcohol  placed  within,  when  it  should 
be -applied,  or  by  attaching  to  its  top  a  stout  piece  of 
rubber  tubing,  through  which  the  air  is  thinned  by 
means  of  a  suction  syringe  like  in  Junod's  apparatus. 
•  At  first  I  made  extensive  use  of  dry  cupping  glasses  for 
the  production  of  hyperemia  and  employed  giant  appa- 
ratus shaped  to  suit  various  large  portions  of  the  body. 
I  have  used  these  apparatus  especially  for  the  treatment 
of  lupus.  Now  I  scarcely  use  them  at  all,  for  the  rea- 
son that,  first,  the  larger  cupping  glasses  can  not  be 
made  to  stick  more  than  a  few  minutes  and,  second, 
because  excision  is  a  far  more  certain  and  better  remedy 
in  small  lupus.  That  cupping  glasses  are  not  suitable 
for  an  extensive  lupus  of  the  face  is  obvious.  (The 
Finsen  light  is  now  a  recognized  and  efficient  remedy  for 
lupus. — Ed.) 

The  cupping  glass  if  attached  to  a  healthy  skin  pro- 
duces, to  judge  from  the  bright  red  color,  arterial  hyper- 
emia; occasionally  when  an  intense  effect  has  been 
achieved  we  observe  an  evidently  venous  hyperemia. 
On  the  other  hand,  when  placed  over  skin  affected  by 
tuberculosis,  according  to  my  experience,  it  always  pro- 
duces a  dark,  venous  hyperemia.  For  this  reason  I  have 
earlier  counted  it  among  the  agents  which  produce  a 
mixed  hyperemia.  The  hyperemia  produced  by  the  cup- 
ping glass  is  perhaps  the  most  vigorous  that  we  are 
capable  of  producing.  If  placed  over  an. ulcerated  part 
of  the  body  it  sucks  in  blood  or  serum,  frequently  both 
at  the  same  time.  According  to  what  has  been  said, 
the  cupping  glass  as  an  agent  for  the  production  of  hyper- 
emia has  so  far  but  little  practical  importance.  Never- 
theless, .  I  think  it  possible  that  there  are  diseases  in 
which  it  may  render  good  service.  Unfortunately  we  do 
not  know  how  this  apparatus  affects  the  deeper  parts. 

86 


HYPEREMIA  BY  DRY  CUPPING  87 

It  has  been  accepted  as  self-evident  that  it  removes  con- 
gestion and  frees  the  deeper  tissues  of  blood-stasis.  This 
has  not  at  all  been  proven.  On  the  contrary,  I  even 
think  it  probable  that  this  agent,  too,  produces  hyper- 
emia  way  into  the  deeper  layers. 


CHAPTER  X 

OTHER  AGENTS  FOR  THE  PRODUCTION  OF 
HYPEREMIA.    "DERIVANTIA." 

For  thousands  of  years  the  so-called  skin  irritants  have 
been  used  against  all  possible  affections.  Although  at 
times  they  have  been  employed  more  or  less  extensively, 
they  have  never  been  entirely  abandoned  and  even  to-day, 
when  their  effect  is  much  disputed,  many  physicians 
make  use  of  them  and  they  are  also  popular  family 
remedies.  The  skin  irritants  are  divided  into  rubefacien- 
tia  (reddening),  vesicantia  and  pustulantia  (producing 
blisters  and  pustules),  and  suppurantia  (tissue-destroy- 
ing and  pus-producing).  From  the  large  number  of  such 
remedies  I  mention  iodine,  alcohol,  opodeldoc,  tincture 
of  arnica,  turpentine,  pitch,  tar,  Spanish  fly,  croton  oil, 
tartarus  stibiatus,  silver  nitrate,  strong  alkalis,  strong 
acids.  The  very  old  view,  that  these  agents  draw  bad 
juices  from  the  diseased  parts,  has  retained  its  hold  to 
this  day.  Of  late,  however,  it  is  the  blood  which  is 
considered  to  have  accumulated  in  too  great  a  quantity  or 
in  a  bad  condition  in  the  affected  parts,  which  should 
be  diverted  to  healthy  parts  in  order  that  it  may  favorably 
influence  the  diseased  ones.  For  this  reason,  these  agents 
were  named  derivantia  or  revulsiva — deviating  agents. 
For  centuries — even  Hippocrates  and  Galen  made  this 
difference — a  derivans  was  the  name  given  to  an  agent 
which  would  deviate  bad  juices  or  stagnant  blood  into 
the  immediate  vicinity,  while  those  which  led  them 
toward  distant  parts  were  designated  as  revulsiva.  If 
the  skin  over  a  diseased  wrist-joint  is  painted  with  iodine, 
it  is  a  derivans.  If,  however,  a  mustard  plaster  is 
applied  to  the  calf  of  the  leg  for  inflammation  of  the 
lungs  we  speak  of  a  revulsivum.  It  is  noteworthy  that 
the  literature  on  these  old  remedies,  which  according 
to  Baftels  (61)  are  used  by  the  diverse  primitive  tribes, 
is  very  meager  and  few  physicians  have  taken  the 
trouble  to  physiologically  explain  their  therapeutic  action. 
I  will  cite  briefly  the  most  important  contribution  on 
this'  subject  which  I  have  been  able  to  find.  We  will 
discuss  first  the  revulsion,  which  plays  such  a  great 

88 


HYPEREMIA   BY    "DERIVANTI A, "    ETC.  89 

role  in  hydrotherapy,  though  under  a  different  name. 
This  point,  it  seems  to  me,  is  important  for  a  better 
understanding  of  the  subject  matter,  although  in  this 
work  we  are  more  concerned  with  local  than  distant 
effects. 

Naumann  (62)  was  the  first  to  attack  the  revulsion  in 
the  sense  of  diversion  of  blood  and  bad  juices.  He  made 
the  following  experiment :  He  amputated  one  of  the  hind 
legs  of  a  frog,  leaving  the  sciatic  nerve  intact  after  the 
animal  was  killed,  by  severing  the  spinal  column  from 
the  head,  avoiding  loss  of  blood.  The  extremity  was, 
therefore,  connected  with  the  rest  of  the  body  only  by 
the  sciatic  nerve.  When  Naumann  stimulated  this  leg 
with  the  faradic  current  on  any  desired  place,  he  found 
this  agent  to  have  an  intense  effect  on  circulation  of 
the  blood,  no  matter  whether  he  observed  under  the 
microscope  the  mesentery,  the  lungs  or  the  web.  Weak 
stimulation  produced  an  acceleration  of  the  blood-cur- 
rent and  increased  activity  of  the  heart ;  strong  stimula- 
tion resulted  in  a  diminution  of  the  blood-current  and 
weaker  activity  of  the  heart.  Similar  results  were  ob- 
tained by  him  when  he  made  the  experiment  on  warm- 
blooded animals  (bats),  the  blood  circulation  of  which 
he  observed  in  the  wing-membrane.  Other  skin  irritants 
had  the  same  effects. 

Naumann  also  made  experiments  on  living  human  be- 
ings, the  proof  of  which,  according  to  our  modern  knowl- 
edge of  physiology,  avails  us  little.  For  this  reason  I 
will  omit  them.  Naumann  drew  from  these  experiments 
the  conclusion  that  a  hyperemia  accompanying  the  irrita- 
tion of  the  skin  need  not  be  considered  and  that  a  diver- 
sion of  blood  from  deeper  to  superficial  parts,  as  was 
generally  accepted,  does  not  exist.  The  curative  effect  of 
the  epispastics  is  produced  by  reflex  by  means  of  the  cen- 
tral nervous  system.  For  this  reason  the  place  of  irritation 
is  of  no  moment  and  the  success  of  the  agents  depends  on 
the  intensity  of  the  cutaneous  irritation  in  so  far  as  weak 
stimuli  increase  the  activity  of  the  heart  and  blood-ves- 
sels in  the  entire  body,  while  strong  stimuli  diminish 
it.  These  observations  were  more  fully  dwelt  on  by 
Naumann  in  later  contributions  (63).  He  found  that  the 
changes  produced  by  a  prolonged  application  of  a  skin 


90  HYPEREMIA  BY    "DERIVANTIA, "   ETC. 

irritant  remain  for  some  time  after  the  cessation  of  the 
irritation.  He  furthermore  asserts  that  the  skin  irritants 
influence  the  bodily  temperature  which  we  may  here 
omit  as  of  no  interest  to  us. 

Schiiller  (64)  also  contributes  an  article  on  revulsion  by 
skin  irritants.  He  trephined  rabbits  and  observed  the 
vessels  of  the  pia  through  the  uninjured  dura  mater.  On 
covering  the  largest  portion  of  the  abdomen  or  back  of 
the  animals  with  mustard  plaster,  he  observed,  aside  from 
some  other  changes  which  do  not  interest  us,  that  the 
arteries  dilated  regularly  in  the  beginning  of  the  effect 
of  the  agents.  For  ten  minutes  the  vessels  varied  in 
their  caliber  to  contract  afterwards,  remaining  in  such 
a  condition  lastingly.  The  entire  brain  shrunk.  The 
mustard  remained  half  an  hour  and  was  then  washed  off, 
but  even  after  its  removal  the  vessels  remained  contracted 
for  one  and  one-half  hours.  During  this  condition  so 
powerful  a  remedy  as  the  inhalation  of  amyl  nitrate  pro- 
duced with  difficulty  in  a  less  degree  than  that  accepted 
as  normal,  a  dilatation  of  the  contracted  vessels. 
Schiiller  is  of  the  opinion  that  these  phenomena  are 
neither  due  to  a  reflex  stimulation  of  the  vessels  of  the 
brain  alone  nor  to  the  "depleting"  effect  of  the  mustard 
plaster  alone.  He  believes  that  in  the  beginning  of  the 
effect  of  the  remedy  a  paralysis  of  the  vaso-motor  nerve 
fibers  is  produced  by  reflex  from  the  skin,  which  causes 
the  moderate  dilatation  of  the  vessels.  If  the  effect  of 
the  mustard  oil  is  continued,  the  developed  intense  hyper- 
emia  and  the  edema  of  the  skin  diminish  the  lateral 
pressure  in  the  rest  of  the  circulatory  apparatus,  or  at 
least  diminish  the  relative  quantity  of  blood  in  it,  there- 
fore being  able  to  also  diminish  the  volume  of  blood  in 
the  brain  vessels.  Schiiller  does  not  wish  to  exclude 
reflex  effects  of  the  oil  even  in  the  later  stages  of  its 
activity. 

On  the  whole  Schiiller  explains  the  effect  of  the  mus- 
tard plaster  by  revulsion  in  the  sense  used  by  the  old 
physicians.  -In  the  same  year  appeared  a  larger  contri- 
bution by  the  same  author  (65)  in  which  he  considered 
the  effects  of  the  employment  of  water  on  the  skin,  which 
can  be  considered  here  only  in  so  far  as  both  cold  and 
heat  belong  to  the  stimuli  of  the  skin.  The  result  ob- 


HYPEREMIA   BY    "DERIVANTIA, "    ETC.  91 

tained  by  Schiiller  briefly  related,  is  as  follows:  Applica- 
tion of  cold  water  to  distant  parts  of  skin  produces  a  dila- 
tation, that  of  warm  water  a  contraction  of  the  vessels 
of  the  pia.  Schiiller  believes  that  reflex  influences  of  the 
cutaneous  nerves  play  in  this  but  a  secondary  role,  and 
that,  if  anything,  they  prove  an  obstacle.  The  changes 
in  the  brain  vessels  he  believes  to  be  essentially  due  to 
contraction  or  dilatation  of  the  circulatory  apparatus  in 
the  skin. 

I  can  pass  over  the  practical  conclusions  which  Schiiller 
has  drawn  from  his  experiments  for  hydrotherapy,  as 
they  do  not  belong  here.  Schuller's  experiments  in  hydro- 
therapy  play  a  great  role.  His  experiments  have  been 
utilized  for  the  explanation  of  certain  effects  of  water  and 
basing  on  them  certain  laws  for  the  application  of  water 
have  been  fixed.  Winternitz  (66)  mentions  them  with 
praise  and  believes  himself  able  to  prove  their  correct- 
ness with  plethysmographic  experiments,  showing  the 
influence  of  the  quantity  of  blood  of  one  bodily  part  on 
another  through  heat  and  cold  effects. 

Matthes  (67)  estimates  the  value  of  Schuller's  experi- 
ments as  of  little  .value.  He  says  that  they  are  so  uncer- 
tain "that  this  kind  of  physiological  experimentation 
scarcely  deserves  being  considered  as  a  scientific  obser- 
vation." 

To  this  may  'be  added  the  experiments  of  Frangois 
Franck,  described  in  Chapter  3,  which  too  have  been  used 
for  the  explanation  of  the  curative  effects  of  water.  T 
can  pass  this  over,  as  I  have  already  recited  my  scruples 
about  the  value  of  these  experiments,  as  they  lead  to 
contradictory  views  on  the  local  effect  of  heat. 

Taken  all  in  all,  we  can  see  that  even  to-day  the  distant 
effects  of  stimuli,  cold  and  heat  included,  are  not  estab- 
lished scientifically  and  that  we  are  compelled  to  rely 
solely  on  experience.  In  this  respeci  we  are  not  any 
farther  than  were  the  old  physicians  with  their  views 
on  venesection  and  Junod's*  hemospasia,  and  finally  we 
come  back  to  the  old  revulsion,  which  appears  here  in  a 
modern  dress.  "While  before  the  change  in  the  distribu- 
tion of  blood  was  explained  mechanically,  we  try  to  do 
so  by  vaso-motoric  influences. 

This   uncertainty   of   explanation   is   well    represented 


92  HYPEREMIA  BY    "DERIVANTIA,"   ETC. 

in  Samuel's  (68)  noteworthy  experiments,  which  must 
be  mentioned  here.  This  physician  showed  that  croton 
oil  applied  to  the  ear  of  a  rabbit  produces  no  inflamma- 
tion as  long  as  the  other  ear  or  even  the  extremities  are 
kept  immersed  in  cold  (below  15°  C.)  water.  Samuel 
was  able  to  avoid  inflammation  for  twelve  hours,  and 
even  after  the  removal  of  the  rabbit  from  the  water  he 
found  that  the  inflammation  was  less  intense  than  under 
normal  conditions.  If  he  made  use  of  scalding  instead 
of  croton  oil  he  could  not  suppress  the  phenomena  of 
inflammation  by  .means  of  cooling,  but  they  were  less 
pronounced. 

We  could  comprehend  these  experiments  if  we  could 
interpret  the  absence  of  inflammation  as  a  reflex  effect. 
But  Samuel  himself  proved  that  this  is  not  the  case,  for 
he  obtained  the  same  phenomena  when  he  cut  through 
the  sympathicus  on  the  crotonized  ear  and  the  nervus 
auriculans  major  and  minor  on  the  one  subjected  to  cold. 
The  noteworthy  facts  so  far  are  entirely  unexplained. 

While  it  is  easy  to  understand  that  the  interpretation 
of  the  distant  effect  of  skin  stimuli  is  extremely  uncertain, 
because  we  are  so  little  familiar  with  the  concerned 
physiological  conditions,  one  would  believe  that  the  local 
effect  of  these  remedies  has  been  studied  thoroughly,  and 
that  there  can  exist  no  difference  of  view  in  regard  to  the 
changes  objectively  perceptible  in  the  region  of  the  appli- 
cation. But  this  is  not  the  case.  The  experiments  un- 
dertaken for  the  investigation  of  the  old  doctrine  of 
revulsion  are  extremely  meager  and  the  individual  results 
contradict  each  other  in  a  great  degree. 

Zulzer  (69),  contrary  to  Naumann,  accepts  the  theory 
of  a  simple  derivation  of  the  blood  by  mechanical  causes 
from  deep  to  superficial  parts,  when  the  latter  are 
attacked  by  skin  stimuli.  He  concludes  this  from  the 
following  experiment  repeatedly  tried : 

For  fourteen  days  the  shaved  back  of  a  rabbit  was  daily 
painted  with  cantharidin  collodium.  On  section  the  skin 
on  the  affected  side  was  suppurating  and  cicatrized,  the 
blood-vessels  below  the  skin  greatly  dilated  and  filled 
with  blood:  Subcutaneous  fat  had  disappeared.  The 
superficial  muscles  were  considerably  hyperemic,  con- 
taining hemorrhagic  places.  The  deeper  muscles,  how- 


HYPEREMIA   BY    "DERIVANTIA, "    ETC.  93 

ever,  were  extremely  pale,  as  compared  with  those  of  the 
healthy  side,  as  were  also  the  chest  wall,  on  the  inner 
surface  of  which  the  difference  was  still  more  prominent. 
The  striking  diminution  in  the  blood  volume  extended 
to  the  musculature  of  the  thigh.  On  frequent  repetition 
of  the  experiment  even  the  lung  of  the  affected  side 
appeared  strongly  anemic,  as  compared  with  that  of  the 
healthy  side.  In  the  vicinity  of  a  seton  he  found  equal 
conditions,  superficially  hyperemia,  in  the  depth  anemia. 

Schiiller  (70)  found  the  skin  of  rabbits  which  he  had 
treated  with  mustard  plaster,  including  the  areolar  tis- 
sue, hyperemic  and  very  much  swollen  "to  a  tough,  jelly- 
like  mass."  The  deeper  parts  he  does  not  mention,  but 
he  states  that  small  mustard  plasters  which  he  applied 
to  the  ear  and  back  of  the  animals,  produced  no  dilatation 
of  the  vessels  in  the  pia. 

Schede  (71)  examined  a  number  of  skin  irritants,  espe- 
cially the  tincture  of  iodine,  as  to  their  local  effects  on  tlr2 
tissues.  He  demonstrated  that  the  tincture  of  iodine, 
when  only  painted  on  the  skin,  produced  the  extravasa- 
tion of  migratory  cells  and  edema  not  only  in  the  skin, 
subcutaneous  areolar  tissue,  muscles  and  muscular  inter- 
spaces, but  the  former  he  found  also  in  the  periosteum 
and  even  demonstrated  inflammatory  irritation  in  the 
bone  marrow  and  phenomena  of  granulation  in  the  cells 
of  the  epiphyseal  cartilages.  As  we  do  not  know  of  any 
such  phenomena  of  inflammation  without  a  previous  and 
accompanying  hyperemia,  we  can  conclude  that  tincture 
of  iodine  applied  to  the  skin  renders  hyperemic  the  tis- 
sues to  the  very  bones. 

Of  late  ^Vechselberg  (32)  has  treated  the  same  sub- 
ject. On  applying  with  a  brush  tincture  of  iodine  or 
other  irritants  for  several  consecutive  days  to  the  skin  of 
the  thigh  of  a  dog,  he  found  an  intense  hyperemia  and 
edema  of  the  skin  and  the  subcutaneous  areolar  tissue 
and  in  the  majority  of  cases  also  of  the  musculature 
situated  below.  In  this  respect  mustard  oil  had  a  more 
decided  effect.  In  all  cases,  furthermore,  there  was  a 
decided  cellular  infiltration  of  the  deeper  layers  of  the 
cutis  and  of  the  subcutaneous  areolar  tissue,  which  as  a 
rule  extended  into  the  musculature.  The  strongest  effect 
in  this  respect  is  obtained  from  croton  oil,  the  weakest 


94  HYPEREMIA  BY   "DERIVANTIA,"   ETC. 

from  tincture  of  iodine.  In  all  experiments,  with  the  ex- 
ception of  those  made  with  mustard  oil,  is  found 
the  remark :  "No  positively  demonstrable  anemia  of  the 
deeper  parts."  In  spite  of  this  Wechselberg,  basing  on 
totally  unproven  theoretic  calculations,  surprisingly  con- 
cludes that  the  skin  irritants  produce  anemia  of  the 
deeper  parts. 

In  my  opinion  such  experiments  as  those  of  Ziilzer  and 
Wechselberg  lead  to  no  result.  I  consider  it  impossible 
to  decide  by  macroscopic  examination  of  deep  parts  in 
sections  as  to  their  volume  of  blood,  especially  in  the 
muscles  of  rabbits  in  which  the  reaction  hyperemia  fol- 
lowing artificial  bloodlessness  can  hardly  be  seen,  as 
I  Jiave  become  convinced  in  my  own  experiments.  In 
such  things  we  surgeons  have  an  entirely  different  ex- 
perience, which  proves  more  than  those  physiological 
experiments.  I  have  always  found  that  in  deeply  situated 
foci  of  inflammation  the  cut  through  the  skin  is  bloodier 
than  in  a  normal  body.  Thus  I  have  even  expressed 
my  suspicion,  when  in  an  exploratory  laparotomy  the 
wound  of  the  abdominal  wall  bled  freely,  that  we  will 
find  in  the  depth  of  the  belly  an  inflammatory  condition, 
and  as  a  rule  I  was  right.  And  yet  we  have  here  to  deal 
with  vascular  areas  which  are  related  only  when  we 
have  insignificant  adhesions:  In  accord  with  this  I  have 
frequently  found  the  temperature  of  the  skin  in  deeply 
situated  chronic  inflammation  (tuberculosis)  elevated 
one  or  more  degrees.  Is  it  possible  that  an  inflammation 
in  the  depth  affects  the  surface  differently  than  if  the 
reverse  is  the  case? 

Besides  this,  other  experiences  speak  for  it  that  the 
stimulus  of  inflammation  renders  hyperemic  neighbor- 
ing regions.  A  deeply  situated  panaris  of  the  palm  causes 
reddening  and  edematous  swelling  of  the  back,  and  un- 
der certain  conditions  even  of  the  entire  forearm.  I 
have  of  late  learned  how  far  a  purely  chemical  inflam- 
mation may  extend  from  the  place  of  application:  I  in- 
jected a  pseudoarthrosis  of  the  thigh,  which  had  resisted 
all  sorts  of  treatment  including  suture  of  the  bones  and 
injection  of  tincture  of  iodine  with  oil  of  turpentine,  and 
caused  it  to  heal  quickly.  But  an  intense  reaction  de- 
veloped. The  leg  became  edematous  from  the  toes  to  the 


HYPEREMIA   BY       DERIVANTIA,"    ETC.  95 

inguinal  fold,  became  everywhere  very  hot  and  remained 
in  this  condition  for  several  days.  These  conditions  were 
experimentally  investigated  by  Samuel  (73)  in  a  contri- 
bution which  is  a  masterpiece  in  macroscopic  observa- 
tion and  in  which  the  author  comes  to  very  similar  re- 
sults. He  produced  an  inflammation  of  the  upper  half 
ear  of  a  rabbit  by  scalding  with  water  of  54°  C.  An 
inflammatory  lesion  develops  immediately,  limited  by  a 
sharp  line  corresponding  to  the  extent  of  the  causative 
factor.  Soon,  however,  the  inflammation  spreads  over 
the  entire  ear,  even  farther  over  the  skin  of  the  head  and 
back.  The  skin  is  edematous,  reddened  and  hot  to  the 
feel.  These  phenomena  reach  their  maximum  after 
eighteen  to  twenty-four  hours  and  disappear  then  grad- 
ually. 

In  my  opinion  the  differentiation  of  various  effects 
of  revulsion  on  deeper  and  less  deeply  situated  parts 
can  but  lead  to  confusion.  For  what  is  cleep  and  what 
less  deep?  If  we,  for  instance,  apply  tincture  of  iodine 
to  the  skin  over  a  pseudoarthrosjs  of  the  thigh,  we  can 
undisputedly  speak  of  a  deep  part,  and  in  accordance 
with  that  view  we  render  the  bone  anemic ;  if  we  apply 
the  iodine  to  the  skin  over  a  pseudoarthrosis  at  the 
lower  end  of  the  radius,  we  have  to  deal  with  a  super- 
ficial part  and  we  render  the  bone  hyperemic.  There- 
fore, in  both  instances  we  would  produce  directly  oppo- 
site results. 

On  careful  consideration  we  can  see  that  whenever 
we  apply  these  theories  we  come  to  contradictions.  For 
the  derivantia  have  proved  themselves  effective  for 
lesions  situated  below  the  skin  or  mucous  membrane  and 
these  in  accordance  with  the  undissented  views  of  the  ex- 
perimenters must  be  regarded  as  superficial  which  also 
are  rendered  hyperemic.  Therefore  they  are  not  con- 
cerned in  the  intended  revulsion. 

I  believe"  that  the  effect  of  revulsion  depends  princi- 
pally on  hyperemia  and  conclude  this  first  of  all  from  the 
fact  that  it  has,  as  a  rule,  the  identical  effect  as  that  ob- 
served from  our  agents  for  the  production  of  hyperemia. 
Their  pain-relieving  effect,  which  has  been  disputed  by 
no  one,  is  striking ;  even  the  opponents  of  these  remedies 
have  had  to  admit  this  and  for  explanation  resorted  to 


96  HYPEREMIA  BY    "DERIVANTIA,"    ETC. 

the  convenient  excuse  that  this  was  due  to  suggestion 
We  will,  however,  later  on  show  that  any  kind  of  hyper- 
emia, active  as  well  as  passive,  has  a  pain-relieving  effect. 
Inasmuch  as  the  derivantia  are  agents  producing  inflam- 
mation and  as  inflammation  produces  a  slower  blood-cur- 
rent, we  will  have  to  compare  their  effect  with  that  of 
passive  hyperemia.  And  both  really  have  identically  the 
same  effect.  The  derivantia  have  been  used  against  in- 
flammation and  pseudoarthrosis  as  resorptive  and  dis- 
solving agents  and  we  will  see  later  on  that  passive 
hyperemia  has  the  same  and  active  hyperemia  some  of  the 
effects.  This  superb  uniformity  in  the  effects  is  by  far 
more  convincing  than  those  uncertain  physiological 
experiments  which  led  to  so  variable  results  among 
the  observers. 

After  I  had  asserted  that  the  favorable  effect  of  the 
derivantia  and  especially  of  heat  on  diseased  parts  is  not 
due  to  the  production  of  anemia  but  hyperemia,  Buch- 
ner  (74)  explained  in  the  same  sense  the  good  results  ob- 
tained from  the  treatment  of  infectious  diseases  by  means 
of  Salzwedel's  alcohol  dressing.  I  have  no  doubt  that 
alcohol,  especially  in  the  form  of  Salzwedel's  dressing, 
belongs  to  the  class  of  derivantia,  and  this  has  been  cus- 
tomary for  some  time,  irrespective  whether  the  alcohol 
was  applied  pure  or  in  the  form  of  a  tincture  with  the 
addition  of  some  other  skin  irritant ;  nevertheless  I  do 
not  agree  with  the  experiments  cited  by  Buchner  as 
proof.  His  experiments  are  weak,  because  it  is  quite  a 
different  thing  to  produce  hyperemia  by  the  hypodermic 
injection  of  alcohol  and  to  assert  that  the  drug  applied  to 
an  uninjured  skin  produces  the  same  result  in  the  deeper 
tissues.  If  this  were  really  so,s  with  the  exception  of 
normal  saline  solution  and  artificial  blood  serum,  there 
would  scarcely  be  a  liquid  remedy  which  would  not  pro- 
duce hyperemia.  They  all  are  irritants  which,  when  in- 
jected into  the  tissues,  finally  produce  inflammatory 
hyperemia.  It  is  just  as  false  to  conclude  from  the  in- 
creased blood  pressure,  observed  by  Buchner  and  his  col- 
laborators, a  hyperemia  or  an  acceleration  of  the  blood- 
current,  for  we  know  from  a  rich  physiological  and 
clinical  experience  that  often  extreme  local  anemia  and 
diminution  of  the  blood-current  is  associated  with  in- 


HYPEREMIA  BY    "DER1VANTIA,"    ETC.  97 

creased  blood  pressure  while  enormous  hyperemia  and 
acceleration  of  the  blood-current  is  accompanied  by  a 
lessened  blood  pressure.  , 

An  experiment  made  by  Heinz  (75)  seems  to  me  to 
offer  better  proof  for  the  hyperemic  effect  in  the  depth  by 
the  alcohol  dressing-.  This  experimenter  demonstrated 
by  means  of  thermo-electric  needles  a  temperature  in- 
crease of  0.15  to  0.25°  C.  in  the  pleura  after  the  applica- 
tion of  an  alcohol  dressing  to  the  external  skin  of  an 
'animal.  The  application  of  the  actual  cautery  to  the  skin 
is  also  counted  among  the  derivantia.  This  too  is  an 
ancient  remedy  which  occasionally  has  been  forgotten, 
but  again  and  again  restored  to  its  place  and  of  late  again 
made  popular  by  Rust.  Even  to-day  it  is  not  entirely  for- 
gotten as  a  "derivans"  and  is  used  against  painful  and 
stubborn  inflammation  of  the  vertebrae,  in  which  the  skin 
is  cauterized  at  both  sides  of  the  cornua.  That  this  remedy 
produces  an  intense  hyperemia  of  the  skin  goes  without 
saying;  that  a  hyperemia  is  produced  also  in  the  depth 
is  probable,  for  if  the  burn  does  not  remain  aseptic  and 
the  wound  is  healing  "below  the  scar,"  a  prolonged  in- 
flammatory hyperemia  will  be  the  natural  result.  This 
will  be  especially  the  case  if  suppuration  be  maintained, 
as  has  been  the  custom,  by  the  introduction  of  peas  or  by 
the  application  of  cantharidin  collodium. 

Two  comparatively  new  contributions  consider  the 
effect  of  the  cautery  on  the  blood  volume  in  the  deeper 
vessels.  Wolter  (76)  reports  the  post-mortem  finding  in 
a  case  of  tetanus,  in  which  Busch,  two  days  before  death, 
burned  two  strips  alongside  the  vertebral  column  with 
the  cautery  in  order  to  effect  the  spinal  cord.  "On  sec- 
tion the  musculature  of  the  back  was  of  a  dark  brownish 
color,  soft  and  flabby,  the  veins  in  the  vicinity  of  the 
spinal  column  intensely  hyperemic.  The  space  of  the 
spinal  canal  exterior  to  the  dura  was  filled  with  a  loose 
blood  coagulum.  It  made  the  impression  as  if  a  delicate 
stratum, of  connective  tissue  was  strongly  infiltrated  with 
thin  blood  mixed  with  serum.  The  dura  mater  was 
strongly  imbibed,  the  pia  mater  decidedly  hyperemic  and 
somewhat  edematous."  Wolter  then  experimented  with 
rabbits  and  found  that  when  he  cauterized  the  skin  at  the 
sides  of  the  spinal  column  not  only  the  muscles  below 


98  HYPEREMIA  BY   "DERIVANTIA, "    ETC. 

the  skin,  but  also  the  spinal  column,  the  meninges  and 
even  the  cord  itself  became  hyperemic. 

Schwering  (77)  confirmed  Wolter's  experiments.  Tie 
found  with  the  same  experiments  hyperemia  reaching  the 
meninges.  Among  three  experiments  he  found  once,  after 
cauterizing  a  strip  5  cm.  long  and  2  cm.  wide  over  the 
skin  in  the  region  of  the  stomach,  that  the  abdominal 
wall  and  the  anterior  wall  of  the  stomach  were  hyperemic. 
"At  some  distance  from  this  hyperemic  place,  however, 
the  wall  of  the  stomach  was  plainly  anemic." 

In  the  other  experiments  Schwering  could  not  confirm 
Zulzer's  statement  concerning  the  production  of  anemia 
in  the  depth  by  the  derivantia.  Nevertheless,  he  sur- 
prisingly draws  the  conclusion  from  the  finding  in  the 
stomach  that  the  cautery,  like  all  derivantia,  "produce 
in  the  immediate  vicinity  hyperemia  ancl  somewhat  far- 
ther away  hyperemia." 

I  have  already  mentioned  above  that  I  place  very  little 
value  on  the  post-mortem  findings  as  regards  the  volume 
of  blood  of  individual  bodily  parts.  Nevertheless,  the 
former  find  is  of  greater  value  than  the  latter  because  on 
cutting  into  hyperemic  organs  the  blood  flows  easily  and 
besides  one  never  knows  when  muscles  and  viscera  did 
not  express  the  blood  in  the  contractions  before  death. 
But,  in  my  opinion,  quantities  of  blood  can  be  found  even 
in  places  where  it  was  absent  before  death  and  the  uncer- 
tainty of  these  experiments  is  evident  from  Welter's 
statement  that  he  has  found  hyperemia  extended  to  the 
spinal  canal  even  in  the  healthy  control  animals.  For  me 
the  only  proof  for  hyperemia  in  the  depth  following  the 
application  of  the  cautery  to  the  skin  is  the  post-mortem 
finding  of  the  patient  reported  by  Wolter.  Here,  below 
the  burn,  in  the  spinal  canal  was  a  turbid  blood  coagu- 
lum,  the  dura  mater  was  imbibed,  the  pia  mater  edema- 
tous.  The  cautery,  therefore,  has  produced  in  the  depth 
changes,  which  all  strong  derivantia  produce,  namely, 
hemorrhages  and  phenomena  of  inflammation  which 
could  be  neither  post-mortem  appearances  nor  artificial 
products.  I  scarcely  need  to  add  that  I  also  consider 
the  actual  cautery,  this  most  powerful  of  all  derivantia, 
as  an  agent  producing  hyperemia.  A  consideration  of 
the  mox£e,  setons  and  fontanelles,  which  belong  to  the 


HYPEREMIA   BY    "DERIVANTIA, "    ETC.  99 

same  class,  would  require  too  much  space.  I  only  re- 
mark, in  order  not  to  be  misunderstood,  that_J  do  not 
mean  to  deny  reflex  action  of  the  derivantia  and  revul- 
siva  on  distant  parts  and  I  admit  that  there  exists  a 
possibility  to  thus  produce  cures.  Nevertheless,  we  must 
be  content  with  mere  suppositions.  However,  I  believe  t3 
have  positively  proven  one  of  the  possible  curative  effects 
of  the  derivantia.  namely,  that  their  main  effect  is  the 
production  of  hyperemia  in  the  affected  parts.  In  this 
respect  they  do  the  opposite  as  indicated  by  their  name. 

Even  the  effect  of  some  internal  remedies,  in  part,  at 
least,  depends  on  the  production  of  hyperemia  which 
they  produce  on  certain  bodily  parts.  We  know  of  salic- 
ylic acid  that  it  produces  a  decided  hyperemia  of  per- 
ipheral parts.  Thus  is  explained  the  reddening  of  the 
skin,  sweating,  tinnitus  aurium  and  disturbances  ot  vis- 
ion observed  from  its  use.  A  similar  effect  is  obtained 
from  alcohol.  Tartarus  stibiatus,  taken  internally,  pro- 
duces in  addition  to  reddening  of  the  skin  and  exanthe- 
mata enormous  hyperemia  of  the  mucous  membranes. 
I  believe  it  possible  that  the  favorable  influence  of 
salicylic  acid  in  acute  articular  rheumatism  is  based  on 
this  ability  to  produce  hyperemia,  for  we  will  see  later  on 
that  the  production  of  artificial  hyperemia  of  the  joints 
affected  with  the  disease  also  quickly  relieves  the  pain 
and  swelling.  With  this  theory  agrees  the  fact  that 
salicvlic  acid  as  a  remedy  producing  hyperemia  only  in 
peripheral  parts,  has  an  effect  only  on  affections  of  the 
joints,  leaving  unaffected  inflammation  of  internal  organs, 
especially  inflammation  of  the  pericardium  which  it 
neither  prevents  nor  removes. 

I  already  stated  that  massage  and  electricity,  in  addi- 
tion to  other  effects,  also  produce  hyperemia.  In  ex- 
plaining the  favorable  influence  of  these  remedies  on 
disease  hyperemia  must  also  be  considered,  naturally. 
I  also  consider  Priessnitz'  compress  as  an  agent  pro- 
ducing hyperemia. 

In  conclusion  I  must  mention  Finsen's  light  treatment 
of  lupus.  Aside  from  other  effects  this  treatment  has  the 
following  result  (78)  :  "Immediately  after  such  a  treat- 
ment the  skin  appears  red  and  swollen ;  this  reaction 
gradually  increases,  reaches  in  about  twenty  minutes 


100  HYPEREMIA  BY    "DERIVANTIA,"   ETC. 

the  maximum,  usually  with  the  formation  of  a  blister. 
If  external  impurities  are  kept  away  the  reaction  ends 
after  eight  to  ten  days  with  a  superficial  exfoliation. 
There  yet  remains  an  intense  redness  which  totally  dis- 
appears only  after  several  months.  This  inflammatory 
process  has  undoubtedly  a  great  importance  for  the  suc- 
cess aside  from  the  bactericidal  effect." 

We  thus  can  see  that  even  in  the  cure  of  lupus  by  light, 
hyperemic  processes  are  also  at  play,  just  as  is  the  case 
when  lupus  disappears  under  the  influence  of  erysipelas. 
It  is  therefore  clear  that  numerous  agents  are  at  our 
disposal  for  the  production  of  hyperemia  and  it  may 
appe'ar  one  sided  that  I  limit  myself  to  only  two  kinds. 
On  careful  consideration  we  will  find  that  this  is  neces- 
sary. For  in  these  remedies  we  have  the  two  extremes : 
on  one  hand  the  great  acceleration  of  the  blood-cur- 
rent by  hot  air,  on  the  other  hand  any  desired  diminution 
by  means  of  the  stasis  bandage  and  the  cupping  appa- 
ratus. We  can  thus  not  only  study  the  pure  effects  of 
hyperemia  but  also  nicely  establish  when  the  various 
kinds  of  hyperemia  have  a  like  or  unlike  effect.  Be- 
sides I  believe  that  there  is  not  another  agent  which  can 
produce  both  extreme  forms  as  intensely  and  this,  after 
the  limits  have  been  established,  without  damage  to  the 
body.  All  those  remedies  which  act  somewhat  like  the 
derivantia  do  so  only  indirectly  by  injuring  the  tissues, 
just  as  is  the  case  in  inflammation,  and  they  do  not  per- 
mit of  exact  dosage  as  we  can  never  say  in  advance  how 
long  and  how  intensely  a  mustard  plaster,  for  instance, 
will  affect  a  given  individual.  Both  our  agents,  on  the 
contrary,  if  properly  applied  do  not  injure  the  tissues  and 
can  be  measured  as  regards  dose  just  as  an  internal 
medicine. 


"OF/Tf-f 


CHAPTER   XI 


INFLUENCE  OF  HYPEREMIA  ON  THE 
LYMPH-CURRENT 

The  answer  to  the  following  question  seems  of  great 
importance :  How  do  the  agents  producing  hyper- 
emia  affect  the  lymph-current?  We  will  not  here 
discuss  the  dispute  in  regard  to  the  origin  of  the  lymph, 
whether  it  is  a  transudate  or  a  product  of  secretion  of 
the  endothelia  of  the  capillaries,  as  it  is  of  no  value  for 
our  purpose. 

The  old  view  which  considered  the  lymph  a  transu- 
date of  the  blood-vessels,  was  based  on  the  self-evident 
fact  that  the  lymph-current  of  a  bodily  part  is  depend- 
ent on  its  blood«  pressure  and  blood  volume.  Accordingly 
any  hyperemia,  active  as  well  as  passive,  must  produce 
an  acceleration  of  the  lymph-current.  This  doctrine  re- 
ceived its  first  blow  through  a  contribution  by  Paschutin 
(79),  which  was  perfected  under  Ludwig's  supervision. 
He  demonstrated  that  the  most  pronounced  arterial  hy- 
peremia which  he  produced  on  the  fore  legs  of  dogs 
remained  without  any  influence  whatever  on  the  celerity 
of  the  lymph-current.  He  produced  hyperemia  by  cut- 
ting the  plexus  brachialis  and  verified  the  appearance  of 
hyperemia  by  demonstrating  an  increase  in  the  tempera- 
ture of  the  extremity. 

Paschutin  did  not  even  notice  an  increase  of  the  lymph- 
current  when,  in  addition  to  the  cutting  of  the  brachial 
plexus,  he  severed  the  cord  of  the  neck  and  stimulated  it, 
though  the  blood  pressure  increased  four  to  nine  times 
and  accordingly  in  the  paralyzed  limb  with  its  dilated 
vessels  the  greatest  possible  arterial  hyperemia  must 
necessarily  have  taken  place.  He  could  not  even  retard 
the  usual  sinking  of  the  lymph-current,  which  always 
occurs  in  prolonged  experiments.  Among  numerous  ex- 
periments he  could  but  twice  produce  a  slight  accelera- 
tion of  the  lymph-current,  but  in  each  instance  could 
demonstrate  that  this  was  due  to  an  evident  error  in  the 
experiments. 

Paschutin's  results  were  confirmed  by  several  others, 
principally  by  Emminghaus  (80),  who  also  labored  under 

101 


2      ZtfFUJBNCE  OF  HYPEREMIA  ON   LYMPH-CURRENT 


Ludwig's  supervision;  also  by  Jankowsky  (81),  who 
worked  with  Cohnheim.  He,  too,  found  that  arterial 
hyperemia,  produced  in  a  normal  extremity  by  paralysis 
of  the  vaso-motors,  does  not  only  not  accelerate  the 
lymph-current  but,  on  the  contrary,  frequently  retards  it. 
If,  however,  he  produced  an  inflamed  extremity  or  if  he 
rendered  the  animals  artificially  hyperemic  then  the  vaso- 
motor  paralysis  accelerated  the  lymph-current.  On  the 
other  hand,  other  experimenters  always  found  the  lymph- 
current  accelerated  and  increased  in  arterial  hyperemia. 
Rogowicz  (82),  who  worked  under  Heidenhayn,  asserted 
that  any  arterial  hyperemia,  no  matter  how  produced, 
as  long  as  it  is  followed  by  an  increase  of  temperature  in 
the  concerned  part,  increases  the  lymph  secretion  and 
accelerates  the  lymph-current.  Paralysis  of  the  vaso- 
motors,  stimulation  of  the  dilators  and  arterial  hyperemia, 
produced  by  poisons,  all  had  the  same  result.  Rogowicz 
ascribes  to  the  following  experiment  the  main  proof:  He 
rendered  half  of  the  tongue  hyperemic  by  repeatedly 
stimulating  the  lingual  nerve  and  injected  at  that  time 
into  the  saphenous  vein  a  saturated  solution  of  sodium 
indigo  sulphate.  The  hyperemic  side  became  quickly 
blue,  while  the  other  parts  at  first  retained  their  normal 
color,  being  dyed  later.  When  the  other  half  of  the 
tongue  also  became  blue  and  if  the  one-sided  hyperemia 
was  prolonged,  the  hyperemic  side  decolorized  much 
more  rapidly  than  the  other  side.  From  this  Rogowicz 
concludes  that  the  lymph  which  carries  the  coloring  mat- 
ter to  the  tissues  is  more  rapidly  excreted  on  the  hyper- 
emic side  and  that  in  prolonged  hyperemia  an  increased 
lymph-current  again  washes  away  more  rapidly  the  color- 
ing matter  in  the  concerned  side.  He  also  found  that  the 
lymph  of  an  arterially  hyperemic  limb,  when  the  condi- 
tions in  the  above-described  experiments  existed,  looked 
more  blue  than  that  of  the  corresponding  other  extremity. 

Pekelharing  and  Mensonides  (83)  also  saw  a  consider- 
able increase  of  the  lymph-current  in  arterial  hyperemia 
of  a  hind  leg  which  they  had  produced  by  cutting  through 
the  sciatic  nerve. 

Chabbas  (84),  who  worked  under  Griinhagen,  could 
demonstrate  that  "the  secretion  of  the  humor  aqueus  is  a 
direct  function  of  the  blood  pressure."  He  showed  that 


INFLUENCE   OF   HYPEREMIA   ON    LYMPH-CURRENT        103 

the  lowering  of  the  blood  pressure  by  narcosis  with 
chloral  hydrate  diminished,  while  increase  of  the  pressure 
by  nicotin  or  ligation  of  the  aorta  above  the  diaphragm 
increased  the  secretion  of  the  humor  aqueus. 

These  observations  have  been  confirmed  by  others 
with  still  more  exact  experiments  and  in  a  more  recent 
contribution  Leber  (85)  has  recognized  their  correct- 
ness. If  the  experiments  concerning  the  dependence  of 
the  lymph  secretion  on  blood  pressure  and  fullness  of 
the  vessels  are  to  be  decisive,  first  of  all  the  certain 
proof  must  be  established  that  humor  aqueus  and  lymph 
are  one  and  the  same.  Many  investigators,  it  seems  to 
me,  have  a  broad  conception  of  the  term  lymph.  Thus, 
Emminghaus  (86)  counts  edema,  hydrops,  anasarca,  hy~ 
drothorax,  a.scites  as  belonging  to  it  and  asserts :  "Edema 
and  increased  1-ymph  secretion  are  identical."  If  we 
furthermore  consider  the  unnatural  conditions  under 
which  these  experimenters  worked — animals  poisoned 
with  nicotin  and  curare,  whose  spinal  cords  and  nerves 
were  cut, whose  aortas  ligated,and  artificial  respiration  in- 
duced— we  will  doubt  the  strength  of  proof  produced 
by  these  experiments  and  understand  the  entirely  differ- 
ent results.  We  must  therefore  draw  the  conclusion : 
We  do  not  know  whether  and  how  the  arterial  hyperemia 
affects  the  lymph-current. 

Just  as  different  as  these  views  are,  just  as  pleasingly 
unanimous  are  those  held  in  regard  to  the  influence  of 
stasis  hyperemia  on  the  lymph-current.  All  observers, 
without  exception,  found  the  excretion  and  the  current 
of  lymph  greatly  increased  by  it. 

The  first  experiments  on  this  subject  were  made  by 
Tomsa  (87).  When  he  checked  the  venous  blood-stream 
at  the  spermatic  cord  while  the  arterial  flow  remained 
unchanged,  the  current  in  the  related  lymph-vessels  be- 
came considerably  increased. 

Emminghaus  (88)  made  the  same  discovery  on  the 
legs  of  animals  as  did  Gonitschewsky  (89),  a  pupil  of 
Cohnheim.  He  produced  the  stasis  hyperemia  with 
plaster  of  Paris  pulp  which  he  injected  into  the  veins  of 
limbs  artificially  rendered  bloodless,  permitting  it  to  dry 
therein.  As  soon  as  this  was  reached  he  released  the  blood- 
current  and  a  decided  stasis  hyperemia  resulted.  This 


104       INFLUENCE   OF   HYPEREMIA   ON   LYMPH-CURRENT 

was  followed  by  a  decided  dilatation  of  the  lymph-ves- 
sels and  increased  lymph-current.  The  intercepted 
lymph  was  liquid  and  thin,  contained  many  red  and 
few  white  blood  corpuscles  and  was  but  slightly  coagu- 
iable. 

Pugliese  (89)  made  similar  observations  when  he  pro- 
duced stasis  hyperemia  in  the  fore  leg  of  an  animal  by 
compressing  the  subclavian  vein.  But  he  found  in  the 
majority  of  cases-  no  change  in  the  color  and  the  solid 
constituents  of  the  lymph.  This  difference  from  the  find- 
ing of  the  previous  observer  is  explained  by  the  fact 
that  the  former  with  the  plaster  of  Paris  pulp  produced 
an  enormous,  while  Pugliese  with  the  compression  of 
the  subclavian  vein  obtained  but  a  moderate  stasis. 

At  an  earlier  date  Lassar  (90)  proved  that  also  inflam- 
mation considerably  increases  the  lymph-current.  He 
therefore  came  to  the  conclusion  that  both  stasis  and 
inflammation  considerably  increase  the  lymph-current. 
Both  kinds  of  lymph  show  vast  differences :  the  lymph 
due  to  inflammation  is  a  yellowish,  tenacious,  easily  coag- 
ulating liquid  containing  many  white  but  few  red  blood 
corpuscles,  and  on  drying  leaves  a  residue  which  exceeds 
considerably  that  of  normal  lymph  and  many  times  more 
than  that  of  stasis  lymph.  Stasis  lymph,  on  the  other 
hand,  is  a  thin  liquid,  slightly  reddish,  imperfectly  coagu- 
lating and  containing  many  red  and  white  blood 
corpuscles.  When  Lassar  added  to  the  inflammation  an 
arterial  hyperemia  by  cutting  the  sciatic  nerve,  this  had 
no  influence  on  the  lymph-current. 

All  these  investigators  produced  the  stasis  hyperemia 
by  ligating  or  compressing  the  larger  vein  trunks,  by  in- 
jection of  plaster  of  Paris  pulp  or  imperfect  constriction 
of  the  concerned  extremity  as  we  do  it  in  our  stasis  hyper- 
emia. But  even  in  the  last  instance  they  intercepted  the 
lymph  from  a  vessel  below  the  constricting  band.  The 
outflow  of  lymph  was  therefore  not  prevented  in  any  of 
their  experiments.  Matters  are  different  with  our  stasis 
hyperemia  produced  with  bandage  or  cupping  apparatus. 
We  constrict  the  lymph-vessels,  too,  and  as  these  have 
still  more  delicate  walls  than  the  veins,  we,  in  all  proba- 
bility, produce  even  a  more  perfect  lymph  than  blood- 
stasis. 


INFLUENCE  OF  HYPEREMIA  ON  LYMPH-CURRENT      105 

Those  experiments,  the  correctness  of  which,  consider- 
ing the  equal  results,  can  not  be  doubted,  can  be  taken  in 
account  by  us  only  in  so  far  as  we  must  accept  that 
after  removal  of  the  stasis  bandage,  that  is  to  say,  in  the 
intervals,  the  lymph-current  is  increased. 

I  already  mentioned  that  we  have  a  kind  of  stasis 
formerly  designated -as  "white  stasis,"  which  appeared  to 
me  to  retain  the  lymph.  At  the  same  time  the  hyperemia 
falls  in  the  background,  but  nevertheless  the  extremities 
swell  and  become  edematous.  When  the  hyperemia  is 
absent  the  skin  looks  white.  One  sees  this  form  of  stasis 
very  rarely.  I  have  observed  it  in  tuberculous  joints  and 
do  not  like  it,  as  it  proved  entirely  ineffective. 


B.     GENERAL  EFFECTS  OF 
HYPEREMIA 


CHAPTER   XII 

ANALGESIC  EFFECTS  OF  HYPEREMIA 

There  is  hardly  an  effect  of  .hyperemia  which  is  more 
striking  than  that  of  the  relief  of  pain.  Both  active  and 
passive  hyperemia  have  this  property.  We  can  observe 
almost  regularly  how  a  joint  attacked  by  painful  chronic 
rheumatism  becomes  less  sensitive  and  occasionally  in- 
sensible after  a  treatment  for  one  hour  in  the  hot-air 
apparatus.  The  influence  of  stasis  hyperemia  on  the 
furious  pains  in  grave  forms  of  gonorrheal  arthritis  is 
much  more  pronounced.  The  pains  grow  less  in  half 
an  hour  to  one  hour  after  application  of  the  rubber 
bandage.  I  will  describe  the  astonishing  and  decided 
results  as  regards  the  relief  of  pain  in  these  cases  in  the 
course  of  this  work.  But  in  all  other  painful  diseases  in 
which  hyperemia  can  be  employed  with  success,  relief 
of  pain  is  always  its  most  prominent  feature.  The  vari- 
ous forms  of  hyperemia  remove  neuralgias  and  headache 
and  diminish  to  a  considerable  extent  the.  sensitiveness 
of  joints  which  have  become  painful  from  various  causes. 

Earlier,  when  my  experiments  with  the  treatment  by 
hyperemia  were  applied  to  a  limited  number  of  diseases, 
I  was  inclined  to  look  upon  this  peculiar  relief  of  pain  as 
mediate,  in  so  far  as  the  cause  of  the  disease  was  influ- 
enced by  the  hyperemia  and  with  its  removal,  also  its 
symptoms,  among  which  belongs  the  painfulness.  I  am 
still  of  llu-  belief  that  this  may  play  a  role  in  the  removal 
of  the  pain.  \Ye  can  conceive  that  the  active  hyperemia 
washes  away  poisonous  substances  which  produce  pain 
by  injuring  the  nerve  endings,  while  the  passive  hvoer- 

107 


108  ANALGESIC  EFFECTS  OF  HYPEREMIA 

emia  attenuates  them.  Something  similar  may  be  the 
case  in  injured  joints,  in  which  hyperemia  relieves  pain. 
However,  the  ability  to  lessen  sensibility  must  be  looked 
upon  as  a  general  property  of  hyperemia  proper.  This 
conclusion  will  be  reached  when  we  remember  that  the 
relief  in  some  cases  come,s  on  so  rapidly — in  less  than 
an  hour — that  there  can  be  no  question  of  a  serious 
influence  of  the  remedy  on  the  cause  of  the  disease. 

Lately  my  assistant,  Dr.  Ritter  (91),  has  experimental- 
ly produced  the  proof  that  indeed  every  form  of  hyper- 
emia diminishes  the  sensibility  of  pain  in  the  tissues. 
For  a  scientific  explanation  of  this  fact  I  refer  to  the 
contribution  by  this  author. 

Active  and  passive  hyperemia  alike  relieve  the  pains 
met  with  in  a  series  of  diseases,  e.  g.,  in  all  chronic, 
painful,  stiff  joints,  be  these  due  to  chronic  rheumatism, 
arthritis  deformans,  injuries  or  other  causes.  In  all 
acute  painful  infectious  diseases,  e.  g.,  arthrites  due  to 
gonorrhea,  acute  rheumatism,  tuberculosis,  passive  hy- 
peremia excels  also  in  its  pain-relieving  effect,  while 
it  seems  to  me  neuralgias  are  better  influenced  by  active 
hyperemia.  At  any  rate,  we  must  completely  abandon 
the  old  view  that  hyperemia,  e.  g.,  the  inflammatory 
hyperemia,  as  such,  produces  pain,  for,  on  the  contrary, 
these  are  due  to  the  injury  to  the  cells  and  nerve  endings 
which  is  found  in  every  inflammation,  and  the  subsequent 
hyperemia  with  its  changes  far  from  producing  or  in- 
creasing pain,  decidedly  diminishes  it.  The  well-known 
"thermic"  diminution  of  pain  is,  in  my  opinion,  pro- 
duced purely  by  hyperemia,  and  it  is  a  crude  error  to 
believe  that  the  heat  freed  the  painful  parts  from  blood 
by  revulsion  or,  as  it  was  usually  termed,  by  "decon- 
gestion." 

My  discovery  of  the  analgesic  effect  of  passive  hyper- 
emia stands  in  direct  opposition  to  the  medical  views 
entertained  heretofore,  for  it  was  considered  self-evident, 
proven  by  daily  experience,  that  blood-stasis  produces 
pain.  I  know  that  my  attempts  to  cure  the  pain  in 
inflamed  limbs  with  stasis  hyperemia  were  received  with 
wary  shaking  of  the  head.  Nevertheless,  I  would  not 
think  of  wasting  time  by  producing  proofs,  for  if  there 
is  anything  in  medicine  easy  to  demonstrate  it  is  this, 


ANALGESIC  EFFECTS  OF  HYPEREMIA         109 

and  every  one  who  is  seriously  inclined  to  be  convinced 
can  do  so  any  time.  All  I  ask  is  that  when  these  experi- 
ments are  made,  make  them  properly  and  do  not  apply 
the  stasis  bandage  so  firmly  that  grave  disturbance  in 
the  nutrition  of  the  tissues  develops  and  the  pressure  on 
the  nerves  causes  violent  pain.  I  can  only  reply  to  those 
who  have  reported  that  the  stasis  hyperemia  produces 
pain,  that  they  do  not  know  how  to  execute  the  technic. 
The  analgesic  effect  of  hyperemia  is  not  only  useful  in 
so  far  as  this  is  agreeable  to  the  patient  but  also  be- 
cause soon  after  its  application  it  restores  mobility  to 
the  stiffened  joints.  The  stiffness  of  the  joints  in  all 
inflammations  is  caused  partially  by  gross  anatomic  dis- 
turbances and  partially  produced  and  maintained  by  con- 
traction of  the  muscles,  which  again  are  due  to  painful 
irritation  of  the  nerves  in  the  joint.  With  the  disap- 
pearance of  the-  irritation  the  contractions,  too,  cease. 
Only  in  this  way  can  it  be  explained  why  after  the  appli- 
cation of  an  agent  producing  hyperemia  stiffened  joints 
become  mobile  so  rapidly.  To  be  sure,  soon  after  the 
discontinuance  of  the  remedy  pain  and  stiffness  return 
and  it  would  be  only  an  apparent  success  if  the  hyper- 
emia achieved  nothing  but  the  diminution  of  pain  dur- 
ing or  for  some  time  after  its  employment.  Fortunately, 
this  remedy  has  also  numerous  properties,  which  favor- 
ably influence  the  cause  of  the  disease  and  its  anatomical 
sequences,  so  that  the  pain  very  soon  diminishes  or.  dis- 
appears not  only  by  the  hyperemia  proper  but  on  account 
of  the  improvement  of  the  disease  itself.  Of  this  we  will 
soon  have  more  to  say.  Nevertheless,  we  must  ascribe 
an  important  role  to  the  purely  analgesic  effect  of  the 
hyperemia.  It  prevents  the  limbs  from  becoming  fixed 
in  faulty  positions,  to  which  reflex  contraction  of  the 
muscles  leads,  enabling  us  to  undertake  passive  mo- 
tions at  an  early  period  and  otherwise  to  avoid  anatomic 
ankvlosis 


CHAPTER  XIH 

BACTERICIDAL  EFFECT  OF  HYPEREMIA 

If  we  observe  cases  of  infectious  diseases,  such  as  we 
will  soon  describe,  which  not  only  rapidly  improve  and 
heal  under  treatment  with  stasis  hyperemia  but  immedi- 
ately after  the  application  of  the  remedy  experience  a 
sudden  change,  we  will  hardly  be  left  in  doubt  that  we 
have  to  deal  with  a  destruction  or  at  least  attenuation  of 
the  causative  bacteria.  The  experimental  proof  that  hy- 
peremia has  this  property  has  lately  been  established  by 
Notzel  (92)-  He  succeeded  in  keeping  alive  fifty-one  out 
of  sixty-seven  rabbits  of  whose  certain  bodily  parts, 
while  under  the  influence  of  a  vigorous  stasis  hyperemia, 
were  inoculated  with  otherwise  fatal  doses  of  anthrax 
bacilli  and  very  virulent  streptococci.  Only  sixteen  ani- 
mals died.  Without  exception  these  were  animals  in 
which  the  edema  "from  the  very  beginning  had  the 
character  of  a  disturbance  of  nutrition."  In  those  fatal 
cases  that  kind  of  stasis  hyperemia  has  been  used  which 
I  have  designated  as  "cold  stasis,"  to  the  inefficiency  and 
harmfulness  of  which  I  have  repeatedly  called  attention. 
That  it  was  indeed  the  stasis  hyperemia  alone  which 
saved  the  animals  from  death  can  be  concluded  from 
the  fact  that  these  same  animals  were  inoculated  a  few 
weeks  later  with  the  same  bacteria  without  the  use  of 
stasis  hyperemia  and  that  they  all  died,  as  did  the  animals 
used  for  purpose  of  control. 

Of  course,  the  fresh  artificial  infection  is  something 
entirely  different  from  that  of  an  infectious  disease  de- 
veloped in  a  natural  way.  in  which  the  bacteria  have 
adapted  themselves  to  the  conditions  of  the  body  and  to 
a  certain  extent  also  to  its  means  of  defense.  Neverthe- 
less, Xotzel's  experiments  are  of  great  value,  as  they 
undoubtedly  show  that  stasis  hyperemia  as  such  has 
bactericidal  properties.  Naturally  it  has  been  tried  to 
bring  this  bactericidal  effect  in  harmony  with  and  to 
explain  by  the  then  prevailing  theories  of  the  protective 
powers  of  the  single  components  of  blood. 

Thus  Buchner  (93)  is  of  the  view  that  in  stasis  hyper- 
emia we  have  not  to  deal  with  a  blood-stasis  but  with  an 

110 


BACTERICIDAL  EFFECT  OF  HYPEREMIA       111 

increased  accumulation  of  leucocytes  at  the  seat  of  in- 
fection which  kill  the  bacteria  by  sending  alexins  into 
the  serum.  In  contributions  (94)  of  a  later  date,  he 
states  that  the  digestion  and  dissolution  of  the  bacteria, 
like  all  other  organic  substances  in  the  body,  take  place 
through  enzymes  contained  in  the  blood  and  especially 
in  its  decomposed  leucocytes. 

Heller*  thinks  that  the  stasis  hyperemia  retains  the 
products  of  metabolism  of  the  bacteria  and  that  these 
kill  their  producers.  In  the  cure  of  tuberculosis  we, 
therefore,  have  a  sort  of  tuberculin  effect. 

Cornet  (95")  explains  the  curative  effect  of  stasis  hyper- 
emia in  a  similar  manner  as  does  Heller.  He  also  sees 
in  the  retention  of  the  products  of  metabolism  of  the 
tubercle  bacilli  the  essential  but  does  not  recognize  the 
healing  process  as  due  to  their  annihilating  effect  on 
their  producers,  and  believes  that  they  stimulate  the 
tissues  to  the  formation  of  connective  tissue  and  scars, 
which  encapsulate  the  infectious  focus  making  it  harm- 
• 

Richter  (96)  believes  that  "the  successes  of  the  method 
(stasis  hyperemia)  are  due  to  the  circulatory  disturb- 
ance followed  by  margination  and  emigration  of  the  leu- 
cocytes." He  can  see  nothing  else  in  stasis  hyperemia 
save  the  production  of  the  mildest  form  of  inflammation, 
and  places  it  alongside  other  methods  of  treatment  which 
act  similarly  (tuberculin,  cinnamonic  acid,  chloride  of 
zinc,  iodoform). 

\  :  /.el  shares  Buchner's  view  that  the  curative  effect 
of  stasis  hyperemia  takes  place  through  a  concentration 
of  the  bactericidal  power  of  the  blood  at  the  seat  of  in- 
fection, especially  since  he  has  learned  by  microscopic 
examination  that  there  is  a  large  quantity  of  leucocytes 
in  the  transudate.  He  therefore  believes  that  its  pro- 
tective effect  is  superior  to  that  of  normal  blood  serum. 

Hamburger  (97)  has  explained  the  curative  effect  of 

-is  hyperemia  in  a  different  way:     The  stasis  makes 

the  blood  richer  in  carbonic  acid  and  this  increases  the 

bactericidal   property  of  the   serum,   first,   because  the 

carbonic  acid  itself  kills  bacteria,  second,  because  under 

'Expressed  durinc  ft  discussion  in  the  Kioler  physiolofischer  Vorein  (Kiel). 


112       BACTERICIDAL  EFFECT  OF  HYPEREMIA 

its  influence  the  red  blood  corpuscles  swell,  dehydrating 
the  serum  and  increasing  its  concentration  and,  finally, 
because  the  serum  gains  in  diffusible  alkali.  The  latter 
occurs  partially  because  with  the  greater  concentration 
of  the  serum  the  percentage  of  alkali  becomes  greater, 
partially  because  under  the  influence  of  the  carbonic 
acid  alkali  passes  from  the  blood  corpuscles  into  the 
serum  liberating  diffusible  alkali  through  decomposition 
of  the  albuminates  of  the  serum. 

Numerous  bacteriological  examinations  (for  the  litera- 
ture see  originals)  prove  the  influence  of  the  alkalis  on 
the  antibacterial  effect  of  the  blood.  Thus,  for  example, 
according  to  v.  Behring  the  susceptibility  of  rats  to 
anthrax  depends  oh  the  alkalescence  of  the  blood.  V. 
Fodor  could  increase  the  resistance  to  anthrax  by  the 
injection  of  alkali  in  the  blood  and  diminish  it  by  the 
injection  of  lactic  acid.  Furthermore,  in  immunized  ani- 
mals increased  alkalescence  of  the  blood  is  present. 

In  order  to  substantiate  the  correctness  of  his  views, 
Hamburger  cites  a  series  of  observations  by  physicians, 
such  as  the  rarity  of  tuberculosis  among  lime-workers, 
who  inhale,  during  a  great  portion  of  theis  lives,  air  rich 
in  carbonic  acid,  and  the  frequency  of  this  disease  among 
proletarians,  who  nourish  themselves  principally  with 
potatoes.  The  latter  observation  is  to  be  explained  by 
the  fact  that  vegetable  food  diminishes  the  alkalescence 
of  the  blood  while  animal  food  increases  it.  Hamburger 
could  furthermore  demonstrate  that  the  bactericidal 
property  of  blood  is  increased  in  venous  stasis  and  on 
this  he  lays  special  stress — that  the  developed  lymph- 
edema  is  a  stronger  bactericide  than  the  corresponding 
blood-serum,  which  otherwise  excels  normal  lymph.  As 
the  bacteria  are  usually  situated  in  the  lymph  spaces  this 
finding  is  especially  important  and  explains  the  favorable 
effect  of  stasis  hyperemia.  The  bactericidal  property  of 
exsudates  is  increased  by  carbonic  acid  in  proportion  to 
the  increased  amount  of  leucocytes  contained  in  the 
liquid. 

In  a  second  contribution  Hamburger  (98)  examined 
the  influence  of  venous  stasis  on  phagocytosis.  He 
reaches  the  conclusion  that  its  influence  on  chemotaxis 
is  small  and  only  large  quantities  of  carbonic  acid  dimin- 


BACTERICIDAL  EFFECT  OF  HYPEREMIA       113 

ish  the  motility  of  the  leucocytes  to  such  an  extent  that 
they  lose  the  property  of  taking  up  carbon  particles. 

Hamburger  is  careful  enough  to  look  upon  the  bacteri- 
cidal properties  of  carbonic  acid  as  one  of  the  salutary 
influences  of  the  stasis  hyperemia  and  does  not  assert 
that  it  is  the  only  effective  remedy.  Inasmuch  as  it  is 
well  known  from  older  contributions,  confirmed  by  the 
above-named  investigators,  that  in  a  moderate  stasis 
hyperemia — in  a  pronounced  one  the  emigration  of 
leucocytes  ceases — leucocytes  emigrate  in  large  numbers 
to  the  diseased  place,  the  favorable  effect  of  this  remedy 
could  be  conceived  also  in  the  sense  of  Metschnikoff's 
phagocytosis. 

It  is  evident  from  what  has  been  said  that  the  stasis 
hyperemia,  considered  theoretically  according  to  modern 
conceptions  and  theories,  is  a  justifiable  and  logical  rem- 
edy against  diseases  which  are  produced  by  bacteria,  for 
it  is  not  opposed  to  any  of  these  theories  but  is,  on  the 
contrary,  in  accord  with  all  of  them. 

I  am  far  from  underestimating  the  value  of  those  bac- 
teriological investigations,  but  can  not  refrain  from  point- 
ing out  that  they  all  suffer  from  a  certain  one-sidedness. 
This  is  especially  the  case  with  Metschnikoff's  theory  of 
phagocytosis,  which,  according  to  him,  is  the  effective 
?nd  curative  feature  of  the  numerous  phenomena  pro- 
duced by  inflammation.  Let  us  better  take  the  stand- 
point, if  we  look  upon  inflammation  as  something  salu- 
tary, that  nature  does  nothing  uselessly  and  that  all  the 
numerous  changes  which  develop  alongside  and  after  each 
other  have  the  purpose  of  suppressing  or  fighting  infec- 
tion. We  will  then  admit  that  among  the  many  changes 
the  above-mentioned  components  of  blood,  recognized  by 
exact  experiments,  have  a  wholesome  effect,  but  in  addi- 
tion we  will  also  have  to  point  out  that  besides  this  a 
number  of  processes  take  place  which,  too,  may  be  useful, 
but  of  which  at  present  we  have  not  exact  knowledge, 
much  less  of  their  effects.  The  only  thing  which,  in  warm- 
blooded animals,  is  common  to  all  inflammations,  without 
exception,  from  the  simplest  to  the  gravest,  and  which 
takes  rank  over  all  other  phenomena,  is  the  change  of 
circulation  which  always  leads  to  hyperemia  and  which 
so  far  no  one  has  satisfactorily  explained.  We  will,  there- 


114       BACTERICIDAL  EFFECT  OF  HYPEREMIA 

fore,  have  to  recognize  this  process  from  which  all  other 
phenomena  develop  afterwards,  as  the  most  significant 
and  most  important.  For  it  is  not  absent  when  parts  free 
from  vessels  are  irritated  to  inflammation,  and  it  is  the 
hyperemia  of  the  surrounding  vascular  parts  with  which 
the  body  acts  to  the  inflammatory  irritation.  It  even 
happens  that  a  quickly  disappearing  hyperemia  remains 
as  the  only  reactionary  process  to  the  injury  of  the  in- 
flammatory irritation  and  that  further  changes  from  this 
hyperemia  do  not  even  appear.  Here  we  must  conclude 
that  the  hyperemia  in  itself  was  sufficient  to  remove  the 
injury. 

For  this  reason  it  is  but  an  imitation  of  a  natural  heal- 
ing process  when  we  increase  the  already  existing  hyper- 
emia in  certain  bacterial  affections,  and  institute  it  espe- 
cially there  where  it  is  not  sufficient.  For  it  is  theoreti- 
cally conceivable  that  nature  frequently  does  not  accom- 
plish enough  in  such  cases.  We  can,  for  instance,  assume 
that  a  man  whose  body  does  not  react  to  a  tuberculous 
infection  by  a  sufficient  hyperemia,  from  which  the  other 
inflammatory  phenomena  successively  develop,  is  at- 
tacked by  tuberculosis  for  this  very  reason  or  unable 
to  heal  it  after  it  has  taken  hold.  We  can  easily  imagine 
that  certain  bacterial  diseases  are  stubborn- and  chronic 
for  the  reason  that  their  producers  do  not  yield  -the  neces- 
sary inflammatory  irritation  which  again  liberates  the 
healing  forces  of  the  body  and  that  we  can  effectively 
support  nature  by  artificial  aid  in  such  cases.  For  I  have 
repeatedly  asserted  that  the  forces  of  the  body,  though 
one  must  be  blind  not  to  recognize  their  purposiveness, 
are  frequently  imperfect. 

(A  disease  to  which  the  body  does  not  react  with  the 
necessary  inflammatory  hyperemia  and  its  subsequent 
phenomena,  it  seems  to  me,  is  chronic  articular  rheuma- 
tism apart  from  the  acute,  inflammatory  exacerbations 
which  occur  in  this  affection.  Men  attacked  by  it  fre- 
quently have  a  sensation  of  cold  in  the  affected  limbs. 
I  could  demonstrate  in  two  cases  which  I  examined  a 
lower  temperature  of  the  skin  over  the  affected  extrem- 
ities than  is  usual  in  other  chronic  inflammations.  Fur- 
ther experiments  in  this  direction  would  be  opportune. 
And  yet  chronic  articular  rheumatism,  as  I  will  later  dis- 


BACTERICIDAL  EFFECT  OF  HYPEREMIA       llo 

cuss,  is  favorably  influenced  by  all  forms  of  hyperemia. 
Accordingly  we  have  here  a  disease  in  which  the 
natural  forces  are  lacking  and  which  we  must  replace 
artificially.) 

As  is  known,  the  above-cited  theories  on  the  anti-bacte- 
rial properties  of  certain  blood  components  and  cells  have 
been  repeatedly  opposed  and  have  even  to-day  many 
enemies — more  than  the  practitioner  without  a  sufficient 
familiarity  with  the  literature  believes — so  that  none  of 
them  enjoys  general  recognition.  Most  of  these  are 
of  no  interest  for  our  purposes  and  I  can  limit  myself  to 
one  objection  by  Spronk  (99),  which  he  has  made  against 
the  observations  of  Hamburger  and  Notzel  in  regard  to 
the  bactericidal  property  of  the  stasis  edema  and  ap- 
parently not  unjustly:  Just  such  bodily  parts  which  are 
in  an  edematous  condition  are  preferably  attacked  by 
bacterial  diseases.  This  is  so  old  a  surgical  experience 
that  it  is  unnecessary  to  spend  any  more  time  on  it.  To 
this  must  be  added  that  I  myself  had  to  report  grave 
erysipelatoid  inflammation  and  suppuration,  which  oc- 
curred in  extremities  subjected  to  stasis  hyperemia.  T 
soon,  however,  found  out,  as  already  mentioned  in 
Chapter  7,  that  there  existed  an  error  in  technic  and  that 
these  undesirable  accidents  occur  only  when  an  excessive 
and  prolonged  disturbance  is  produced  by  the  bandage. 
I  have,  therefore,  repeatedly  warned  that  for  prolonged 
employment  only  hot  stasis  is  effective,  while  cold  stasis 
may  have  bad  consequences  as  it  may  lead  to  serious  cir- 
culatory disturbances.  I  can  report  that  the  hot  stasis, 
instead  of  leading  to  erysipelatoid  and  other  infectious 
diseases  in  the  stased  limbs,  on  the  contrary,  opposes 
these  diseases  most  effectively  and  for  many  of  them  it  is 
the  best  remedy. 

"\Ye  had  to  learn  in  such  cases  like  in  many  methods  of 
physical  therapy — one  need  only  think  of  the  application 
of  water  for  curative  purposes — that  the  useful  and  harm- 
ful of  a  remedy  frequently  are  close  to  each  other  and 
that  one  must  know  and  measure  his  remedies  in  order 
to  do  good.  The  scientific  confirmation  for  these  facts 
is  contained  in  the  above-mentioned  excellent  contribu- 
tion by  Notzel,  who  demonstrated  that  in  order  to  kill 
bacteria  new  blood  and  new  transudate  are  always  neces- 


116        BACTERICIDAL  EFFECT  OF  HYPEREMIA 

sary  and  that  serious  disturbances- of  circulation  and 
chronic  edema,  instead  of  preventing,  tend  to  favor  in- 
fection. For  this  reason  I  do  not  employ  prolonged 
stasis  hyperemia  in  infectious  diseases.  How  to  pro- 
ceed in  the  individual  affections  I  will  explain  in  the 
clinical  part  of  this  book. 

I  am  well  aware  that  my  views  on  the  favorable  effect 
of  stasis  hyperemia  on  infectious  diseases  are  in  direct 
contradiction  to  the  prevailing  doctrines  on  their  treat- 
ment. For  in  surgery  it  was  considered  a  positive  axiom 
that  blood-stasis  is  highly  injurious  to  all  inflammatory 
processes  and  that  the  alpha  and  omega  of  treatment 
was  contained  in  the  removal  of  the  stasis !  For  this 
reason,  when  a  description  of  the  stasis  hyperemia  as  a 
means  to  produce  new  bone  formation  was  given,  it  was 
stated  that  the  remedy  is  "self  evidently"  to  be  entirely 
out  of  question  in  inflammation  of  the  concerned  ex- 
tremities, even  in  chronic  tuberculous  inflammation.  The 
correctness  of  this  opinion  seemed  to  be  borne  out  from 
the  observations  by  the  internists  of  the  so-called  hypo- 
static  pneumonia,  which  was  looked  upon  as  a  conse- 
quence of  the  sinking  of  blood  in  the  dependent  parts 
of  the  lungs.  To  this  came  the  fact  that  the  so-called 
antiphlogistic  regimen,  which  is  designated  by  the  three 
words  "rest,  high  posture  and  ice  for  all  inflammations," 
immediately  improved  grave  and  dangerous  forms  of  in- 
flammation of  the  extremities. 

How  can  these  peculiar  contradictions  be  unified? 
First,  it  must  be  said  in  regard  to  hypostatic  pneumonia 
that  we  have  to  deal  with  special  conditions.  It  is 
produced  by  an  exhaustion  of  the  heart  force,  therefore 
in  debilitated  individuals  whose  natural  capability  of  re- 
action has  suffered,  and,  second,  it  does  not  appear  to  me 
as  proven  that  it  is  the  sinking  of  the  blood  which  is  the 
real  cause  and  not  other  factors,  such  as  deficient  airing, 
and  therefore  deficient  purification  of  the  concerned  parts 
of  the  lungs,  while  the  hyperemia  is  perhaps^only  a  sec- 
ondary condition. 

But  there  still  remains  the  undeniably  favorable  effect 
of  the  antiphlogosis,  of  which  I  myself  have  been  con- 
vinced many  times,  for  I  have  been  trained  in  one  of 
the  strictest  antiphlogistic  schools.  It  is  plain  that  the 


BACTERICIDAL  EFFECT  OF  HYPEREMIA       117 

high  posture  must  act  favorably  in  all  infectious  diseases 
of  the  extremities,  which  are  inclined  to  circulatory  dis- 
turbances and  venous  stasis,  so  that  gangrene  threatens 
to  occur  or  has  already  occurred.  That  an  artificial  in- 
crease of  blood-stasis  can  but  act  injuriously  in  such 
cases  needs  no  further  discussion.  Similarly  the  high 
posture  must  favorably  effect  all  forms  of  chronic  edema, 
the  danger  from  which  we  have  learned  above,  it  re- 
moves the  old  edema  and  permits  new  and  effective  blood 
-and  edema  to  take  its  place. 

As  regards  the  ice-bag,  I  consider  it,  if  applied  for 
some  time,  a  remedy  which  does  not  produce  anemia  but 
hyperemia,  therefore  the  opposite  to  that  expected  of  it. 
It  is  known  that  the  intense  cold  obtained  from  the  ice- 
bag  produces  at  first  a  transient  anemia,  then  a  lasting 
hyperemia.  One  need  only  observe  the  skin  which  has 
been  exposed  to  this  remedy  for  several  hours.  The  cold, 
as  is  proven  by  the  well-known  experiments  of  v.  Es- 
march,  Schlikoff  and  others,  penetrates  deeply  into  the 
tissues  and  we  can  assume  that  hyperemia  follows  the 
stimulation  by  the  cold  also  into  the  depth.  The  hyper- 
emia is  necessarily  passive,  because  otherwise  it  would 
not  be  possible  for  the  cold  to  penetrate  so  deeply,  as 
the  rapid  blood-stream  associated  with  active  hyperemia 
would  quickly  equalize  the  difference  in  temperature. 
Finally  we  must  remember  the  experience  that  frequently 
we  obtain  identical  results  with  apparently  or  really 
opposite  remedies.  Thus  some  physicians  treat  the  chest 
of  a  patient  suffering  from  pneumonia  with  an  ice-bag, 
while  others  apply  a  warm  poultice  and  both  see  good 
results  from  each,  particularly  as  regards  the  relief  of 
pain.  Theoretically,  a  really  opposite,  yet  favorable  re- 
sult can  be  expected  from  both  of  our  remedies  somewhat 
in  this  manner:  Of  late  it  has  been  tried  to  treat  bacte- 
rial diseases  in  two  different  ways :  first,  by  killing  the 
bacteria,  as  in  antisepsis ;  second,  by  annihilation  or 
combination  of  the  injurious  toxins,  as  in  the  anti-diph- 
theritic serum  of  v.  Behring.  Now  let  us  imagine  on  one 
hand  the  stasis  hyperemia  as  a  bactericidal,  on  the  other 
hand  the  antiphlogistic  regimen  as  a  remedy  inhibiting 
the  absorption  and  effect  of  the  toxins,  and  we  have 
reached  in  two  entirely  different  ways  one  and  the  same 


118       BACTERICIDAL  EFFECT  OF  HYPEREMIA 

thing,  namely,  the  favorable  influence  on  the  disease. 
That  the  effect  of  the  toxins  and  especially  their  absorp- 
tion are  strongly  influenced  by  the  antiphlogistic  reme- 
dies is  evident  from  the  previously  cited  contributions  by 
Klapp. 

From  these  statements  it  is  clear  that  the  contradic- 
tions treated  above  are  not  necessarily  as  sharp  as  they 
appear  to  be.  However,  we  have  here  entered  the  do- 
main of  theory  and  in  practical  medicine  experience  plays 
the  main  role.  And  I  believe  to  have  gained  enough  of 
the  latter  to  be  able  to  assert  that  in  reality  these  different 
remedies  do  not  have  so  decidedly  favorable  an  effect  as 
one  is  led  to  believe.  If  we,  for  instance,  treat  an  acutely 
or  subacutely  inflamed  joint,  which  has  no  grave  dis- 
turbances of  circulation,  antiphlogistically,  the  pain  tlis-  • 
appears  rapidly,  inflammation  and  fever  diminish,  but, 
as  a  rule,  the  treatment  is  long  drawn  out,  resulting  too 
often  in  ankylosis.  If  we,  however,  treat  the  same  joint 
with  stasis  hyperemia,  the  pain  disappears,  as  a  rule, 
more  rapidly,  fever  frequently  diminishes  immediately 
and  what  is  more  striking  is  the  resulting  increased  mo- 
bility of  the  joint.  Furthermore,  the  entire  course  of  the 
disease  is  far  shorter.  I  can  not  help  but  be  under  the 
impression  that  in  such  cases  we  have  actually  done 
harm  with  an  antiphlogistic  regimen.  We  have  sup- 
pressed the  phenomena  disagreeable  to  the  patient,  but  at 
the  same  time  also  the  useful  inflammatory  reaction,  thus 
prolonging  the  disease  and,  what  is  most  important, 
causing  the  joint  to  become  stiff.  The  result  from  the 
antiphlogistic  regimen  was  therefore  in  reality  a  failure. 
On  the  other  hand,  antiphlogistic  treatment  is  suitable 
and  useful  when  nature  overreaches  the  mark  with  the 
phenomena  of  inflammation,  especially  with  hyperemia, 
as  I  have  described. 

Previous  to  my  employment  of  stasis  hyperemia  for 
infectious  diseases  I  made  use  of  active  hyperemia  for 
the  same  purpose.  The  first  experiments  with  hyperemia 
were  made  in  the  year  1891  for  a  pronounced  infectious 
disease,  tuberculosis,  by  hot  air.  I  have  described  in  my 
contribution  of  1893  the  complete  failure  of  these  experi- 
ments. With  no  exceptions  I  have  been  able  to  observe 
but  changes  for  the  worse.  These  observations  have  been 


BACTERICIDAL  EFFECT  OF  HYPEREMIA       119 

later  confirmed  by  Thiem  (100),  who  has  had  the  same 
experience.  Besides  I  found  only  two  reports  in  the 
literature  on  the  treatment  of  tuberculosis  with  hot  air. 

Clado  (101),  who,  as  I  have  already  mentioned,  has 
employed  hot  air  for  the  treatment  of  tuberculous  affec- 
tions of  the  joints  at  about  the  same  time  I  did,  with  a. 
view  of  killing  the  tubercle  bacilli  in  the  manner  of 
TyndalTs  "fractional  sterilization,"  reports  that  he  has 
cured  four  out  of  six  joints  affected  with  tuberculosis, 
which  he  treated  daily  for  one  hour  at  a  temperature  of 
1 10°  C.  Further  details  he  does  not  furnish. 

\Yilson  (102)  has  treated  many  cases  of  tuberculosis  of 
the  joints  with  hot  air  but  has  at  the  same  time  fixed 
the  joints.  He  is  of  the  view  that  the  disease  is  favorably 
influenced  by  the  treatment  but  can  not  positively  assert 
this  and  does  not  know  which  of  the  two  remedies  has 
been  effective. 

The  fact  that  one  hears  nowadays  so  little  about  the 
treatment  of  tuberculous  joints  with  hot  air,  which  has 
become  so  popular,  seems  to  indicate  that  the  results 
generally  have  been  bad,  for  the  remedy  certainly  has 
been  used  for  all  possible  joint  troubles,  hence  also  for 
tuberculosis.  I  do  not  believe  that  my  warning  pub- 
lished in  1893  had  a  deterring  effect ;  it  seems  that  it 
either  did  not  become  known  or  was  forgotten  when 
Tallerman's  apparatus  drew  the  attention  of  wide  cir- 
cles to  hot-air  therapy.  Similar  failures  were  experienced 
by  me  with  hot  air  when  I  commenced  to  treat  by  hy- 
peremia  acute  inflammation  of  joints.  To  be  sure,  I  only 
used  it  in  four  or  five  cases  of  acute  gonorrheal  or  rheu- 
matic arthritis  but  throughout  with  bad  results.  There 
either  was  no  improvement  or  the  affections  became 
worse.  At  any  rate,  the  effect  of  stasis  hyperemia 
proved  here  considerably  superior. 

\Yilson,  too,  has  had  no  success  in  the  treatment  of 
acute  articular  affections.  He  expressly  states  that  hot- 
air  therapy  has  no  favorable  effect  on  acute  and  chronic 
gout,  acute  rheumatism  and  in  the  rheumatoid  arthritides. 

Numerous  reports  on  the  favorable  influence  of  hot 
air  on  gonorrheal. inflammation  of  joints  can  be  found  in 
literature.  But  it  is  not  stated  whether  these  really  were 
acutely  inflamed  joints  or  only  the  sequences,  especially 


120        BACTERICIDAL  EFFECT  OF  HYPEREMIA 

stiffened  joints.  In  one  contribution  I  do  not  know 
whether  the  author  has  really  treated  with  hot  air  such 
acutely  inflamed  joints.  Lowenhardt  (103)  states  that 
he  "has  employed  in  all  stages  of  gonorrheal  arthritis  hot 
air  and  has  not  seen  an  injurious  effect  from  it."  Imme- 
diately afterwards,  however,  he  admits  that  "only  when 
the  temperature  was  high  and  in  processes  inclined  to  the 
formation  of  abscesses,  I  had  no  opportunity  or  did  not 
feel  justified  in  proceeding  thermically."  At  any  rate, 
even  from  this  contribution  we  do  not  know  whether 
Lowenhardt  has  obtained  favorable  results  in  acute  or 
only  subacute  inflammation  of  the  joints. 

Recently  Buchner,  in  the  sense  of  the  theory  es- 
tablished by  him,  has  expressed  the  view  that  the  active 
hyperemia  which  he  believes  to  have  produced  by  means 
of  an  alcohol  bandage,  has  a  greater  bactericidal  effect 
than  the  passive  form  obtained  by  blood-stasis.  I  have 
demonstrated  above  that  Buchner  owes  the  proof  that 
the  hyperemia  which  the  alcohol  dressing  produces  also 
in  the  depth  is  really  active  and  not  one  close  to  the 
inflammatory  passive  hyperemia.  Everything  seems  to 
point  that  the  latter  is  the  case. 

Finally  Ullmann  (104)  has  reported  good  results  ob- 
tained from  the  treatment  by  hot  air  of  infected  wounds 
and  bacterial  ulcers.  He  attributes  the  good  results  to 
the  bactericidal  properties  of  the  active  hyperemia  pro 
duced  by  hot  air.  It  is  noteworthy  that  the  infectious 
affections  treated  by  Ullmann  were  only  superficial  ulcers. 
These  I  have  treated  with  hot  air  in  the  very  beginning 
of  my  experiments  and  in  my  first  contribution  I  reported 
an  interesting  case.  Nevertheless,  it  seems  very  doubt- 
ful to  me  whether  we  have  to  deal  with  a  bactericidal 
effect  of  the  active  hyperemia  and  I  have  repeatedly 
expressed  these  doubts.  Here  other  influences  are  brought 
into  play,  namely,  the  bactericidal  effect  of  the  heat 
itself,  which  can  not  be  doubted  because  of  the  super- 
ficiality of  the  ulcers,  the  acceleration  of  demarcation  in 
gangrenous  and  necrotic  processes  and  the  vigorous 
formation  of  granulations. 

If  we  should  investigate  the  question  how  nature  pro- 
ceeds when  it  produces  its  inflammatory  hyperemia,  we 
would  learn  that  in  all  inflammations  it  diminishes  the 


BACTERICIDAL  EFFECT  OF  HYPEREMIA       121 

blood-stream  after  a  transient  acceleration  and  that  this 
diminution  remains  throughout  the  stay  of  the  inflamma- 
tion. If  we,  therefore,  look  on  the  entire  inflammatory 
process  as  something  useful,  we  can  not  avoid  taking 
in  consideration  the  diminution  of  the  blood-stream,  and 
if  we  wish  to  support  nature's  healing  we  must  not  dis- 
turb it  but,  on  the  contrary,  support  it. 

I  have  already  mentioned  that  it  is  difficult  to  determine 
whether  in  the  production  of  hyperemia  we  have  to  deal 
with  an  acceleration  or  a  diminution  of  the  blood-stream. 
This  is  especially  so  when  we  render  inflamed  parts  hy- 
peremic.  For  as  observation  with  the  microscope  has 
shown,  the  inflammatory  irritation,  the  effect  of  which  is 
totally  unknown  to  us,  knows  how  to  diminish  an  origi- 
nally accelerated  blood-stream  and  to  keep  it  thus.  All 
explanations  which  have  been  made  for  this  peculiar  phe- 
nomenon are  entirely  unsatisfactory  and  we  have  there- 
fore to  be  content  with  the  fact  itself.  But  it  is  certain 
that  agents  which  produce  active  hyperemia  per  se,  in  in- 
flamed parts  produce  passive  hyperemia,  as  the  blood- 
stream in  the  vessels  in  the  inflamed  part  becomes  slower. 
The  active  hyperemia  must  not  predominate,  otherwise 
it  will  disturb  the  natural  process  of  reaction.  From  this 
follows  that  we  should  employ  an  agent  producing  an 
intense  active  hyperemia,  and  such  decidedly  is  hot  air, 
while  a  moist  warm  poultice  or  a  hot  compress  may  in- 
crease the  naturalprocess  of  inflammation  because  they 
accelerate  the  blood-stream  in  a  smaller  degree  and  are 
therefore  more  suitable  in  inflammation.  To  this  belongs 
my  above-cited  observation  that  a  cupping  glass  which 
produces  a  bright  red  arterial  hyperemia  in  a  healthy 
portion  of  the  skin  causes  a  dark  venous  hyperemia  when 
placed  over  a  lupus,  that  is  to  say,  chronically  inflamed 
skin.  To  the  extraordinary  violent  ebullitions,  it  seems 
to  me,  can  be  counted  the  hyperemia  following  the  in- 
jection of  Koch's  tuberculin,  and  it  is  possible  that  part 
of  the  changes  for  the  worse  are  due  to  it. 

It  is  opportune  to  point  on  this  occasion  to  the  fact  that 
after  enormous  exertions  associated  with  functional  ac- 
tive hyperemia,  infectious  diseases  frequently  appear  in 
the  overtaxed  parts,  e.  g.,  tuberculosis  and  gonorrhea  of 
the  joints  after  excessive  use  of  the  extremities.  I  will 


122       BACTERICIDAL  EFFECT  OF  HYPEREMIA 

avoid  drawing  this  conclusion,  for  those  observations  can 
be  explained  much  simpler  in  the  unusual  strain  and  in- 
jury of  the  tissues,  which  is  the  consequence  of  each 
exertion.  The  best  we  can  do  is  to  maintain  that  the 
active  functional  hyperemia  is  not  capable  of  warding  off 
the  development  of  those  diseases. 

After  all  reported  experiences  it  seems  to  me  logical 
from  a  purely  theoretical  standpoint,  to  first  of  all  con- 
sider stasis  hyperemia  in  the  selection  of  the  various 
forms  of  hyperemia  for  the  treatment  of  inflammatory 
diseases.  My  practical  results  are  in  accord  with  this 
theoretic  conception.  That  occasionally  active  hyper- 
emia can  be  and  has  been  successfully  employed  is  be- 
yond doubt,  just  as  I  am  positive  that  the  most  intense 
forms  of  active  hyperemia  can  be  injurious  under  cer- 
tain circumstances  in  acute  inflammation  and  that  stasis 
hyperemia  is,  to  say  the  least,  the  superior  one  in  chronic 
and  subacute  inflammation.  It  appears  to  me  queer  that 
more  recent  investigators,  since  for  a  long  time  no  atten- 
tion has  been  paid  to  my  explanation  of  the  described 
remedies  as  producing  hyperemia,  now  take  up  the  mat- 
ter and  apply  hyperemia  after  certain  fixed  theories.  One 
attacks  the  bacteria  with  serum,  the  other  with  leu- 
cocytes, the  third  with  carbonic  acid,  etc.,  without  con- 
sidering that  we  have  to  deal  with  unproven  theories. 
Though  these  theories  are  important  and  fruitful  so  that 
I  would  not  spare  them  under  any  circumstances,  yet 
they  may  become  risky  if  practically  applied  in  their  one- 
sidedness.  We  would  be  in  danger  of  reaching  a  stage 
similar  to  that  which  prevailed  in  hydrotherapy,  in  which 
all  possible  unproven  physiological  experiments  have 
been  applied  to  practice  and  conclusions  drawn  from 
methods  which  have  long  ago  ceased  to  be  recognized  by 
physiologists. 


CHAPTER  XIV 

ABSORPTIVE  EFFECT  OF  HYPEREMIA 

For  some  time  I  have  made  use  of  active  hyperemia 
produced  by  hot  air  for  the  purpose  of  absorption.  I 
learned  early  that  in  chronic  affections  of  the  joints  which 
1  treated  alternately  with  active  and  passive  hyperemia, 
the  former  quickly  removed  the  edema  produced  by  the 
latter.  Basing  on  this  experience  I  employed  active  hy- 
peremia in  the  treatment  of  elephantiasis  and  the  edema 
following  the  healed  fractures  of  the  extremities.  If  an 
absorptive  effect  is  desired,  hot  air  must  not  be  applied 
too  long  as  otherwise  it  will  produce  edema.  I  have  re- 
ported in  my  first  contribution  that  limbs  exposed  to  hot 
air  of  100°  C.  for  eight  to  ten  hours  daily  became  strongly 
edematous.  We  again  see  here  the  peculiarity  of  physical 
remedies,  already  mentioned,  that  yield  variable  results 
depending  on  the  duration  and  intensity  of  their  applica- 
tion, a  feature  which  will  yet  demand  our  attention. 

The  absorptive  effect  of  active  hyperemia  is  in  full 
accord  with  our  modern  scientific  knowledge  of  the  chan- 
nels of  absorption,  for  we  know  that  almost  the  entire 
absorption  of  watery  substances  and  bodies  soluble  in 
water  takes  place  through  the  blood  capillaries  and  not 
through  the  lymph  channels,  as  was  generally  believed. 
This  view  is  undisputed  as  far  as  the  gastro-intestinal 
digestion  is  concerned,  so  that  it  is  unnecessary  to  cite 
proof  from  the  literature,  a  perusal  of  a  modern  text-book 
on  physiology  being  sufficient  for  that.  Absorption  of 
water,  salts,  dissolved  carbohydrates,  peptones  and  some 
unchanged,  soluble  albuminous  bodies  takes  place  almost 
exclusively  through  the  blood  circulation.  Small  quanti- 
ties of  these  substances  have  been  found  in  the  lymph 
channels  only  after  the  ingestion  of  large  quantities.  On 
the  other  hand,  fat,  whether  taken  up  in  a  saponified 
condition  or  in  the  form  of  fine  granules,  is  carried  off 
almost  exclusively  by  the  lymphatics,  but  a  very  small 
portion  apparently  directly  entering  the  blood. 

Similar  conditions  prevail  in  regard  to  the  absorption 
of  materials  from  the  tissues  and  cavities  of  the  body.  It 
has  cost  much  time  and  difficulty  until  this  conviction 

123 


124         ABSORPTIVE  EFFECT  OF  HYPEREMIA 

was  reached.  And,  indeed,  it  seems  peculiar  at  the  first 
glance  that  remedies,  dissolved  in  water  and  injected  into 
the  very  beginnings  of  the  lymph-roots  are  not  taken  up 
and  carried  off  by  them  but  by  the  blood-vessels,  which 
are  separated  by  a  wall.  One  would  rather  think  that  the 
open  lymph  spaces  of  the  abdominal  cavity,  which  v. 
Recklinghausen  has  demonstrated  especially  at  the 
diaphragm,  take  up  fluids  instead  of  permitting  them  first 
to  pass  through  the  wall  of  the  blood  capillaries.  Nu- 
merous experiments,  however,  have  shown  that  this  is 
indeed  the  case  and  that  absorption  occurs  in  a  similar 
way  as  it  does  in  the  digestive  tract.  I  will  omit  the 
fairly  old  experiments  (105)  from  which  the  observers 
concluded  that  tissue  absorption  depends  on  the  general 
and  local  blood  volume  and  cite  from  the  numerous  con- 
tributions some  of  the  more  recent  and  important  ones 
which  offer  decisive  proof. 

Orlow  (106),  a  pupil  of  Heidenhain,  observed  that  dur- 
ing the  absorption  of  fluids  and  salts  which  he  had  in- 
jected into  the  abdominal  cavity,  neither  increased  in  the 
lymph  taken  from  the  thoracic  duct.  Since  they  disap- 
peared from  the  abdominal  cavity  during  the  observation 
they  must  have  been  taken  up  by  the  blood  capillaries. 

Starling,  during  the  absorption  of  sodium  indigo  sul- 
phate from  the  pleural  and  abdominal  cavities,  found  the 
drug  more  in  the  urine  than  in  the  lymph. 

Heidenhain  (107),  in  a  contribution  in  which  he  de- 
fends Orlow's  results  against  attacks  made  by  Cohnstein. 
says :  "On  the  strength  of  Orlow's  experiments  and  my 
own  experience,  I  am  convinced,  now  as  before,  that  the 
most  important  channels  of  absorption  of  the  peritoneal 
cavity  are  the  blood  capillaries,  though  the  possibility 
exists — not  disputed  by  Orlow — that  the  lymph  channels 
of  Recklinghausen  carry  a  small  quantity  of  fluid  to'the 
thoracic  duct." 

Hamburger  (108)  saw  that  after  ligation  of  the 
thoracic  duct  absorption  from  the  abdominal  cavity  took 
place  just  as  rapidly  as  when  the  lymph-current  was  un- 
obstructed. "From  this  follows  by  exclusion  that  the 
blood-vessels  must  be  held  responsible,  if  not  totally,  at 
least  to  a  great  extent."  He  tries  to  prove  by  the  follow- 
ing experiment  that  the  same  condition  prevails  in  regard 


ABSORPTIVE   EFFECT  OF   HVPEREMIA  125 

to  tissue  absorption  :  He  clamped  the  aorta  of  an  animal 
below  the  renal  artery  with- forceps  and  injected  a  solu- 
tion of  potash  of  iodide  in  one  of  the  hind  legs,  the 
vena  cruralis  of  which  he  had  exposed  and  provided 
with  a  small  tube  which  permitted  the  outflow  of  blood 
from  the  foot  end.  He  found  potash  of  iodide  in  the 
venous  blood  of  the  leg.  This  must  have  been  absorbed 
by  the  blood  capillaries,  for  if  the  lymph-current  had 
carried  it  into  the  blood  it  could  not  have  reached  the 
circulation  any  farther  than  the  place  of  ligation  of  the 
aorta. 

Asher  (109)  made  a  similar  experiment.  He  ligated 
the  abdominal  aorta,  exposed  the  arteria  and  vena,  cru- 
ralis, severed  them  and  introduced  canulae.  He  injected 
a  solution  of  sodium  iodide  into  the  tissues.  Hp  now 
caused  an  artificial  blood-current  to  pass  through  the 
extremity  excluded  from  the  circulation,  and  found  iodine 
in  the  blood  coming  from  the  vein.  This  could  have 
been  taken  up  by  the  capillaries  only.  Asher  could 
demonstrate  absorption  of  sodium  iodide  by  the  capil- 
laries by  several  experiments  made  in  a  different  way. 

J.  Munk  (no)  proved  tissue  absorption  through  the 
blood  channels  thus :  He  ligated  the  lymph-trunk  of  the 
neck  and  incised  it  above  the  place  of  ligation  so  that  the 
entire  lymph  of  the  head  was  led  outwards.  Then  he 
repeatedly  injected  poison  under  the  scalp  of  the  animals. 
He  could  note  no  important  difference  in  regard  to  ap- 
pearance and  course  of  poisoning,  irrespective  whether 
lymph  was  let  out  or  not.  There  should  have  been  a 
difference  if  the  lymph-roots  had  absorbed  the  poison. 
The  poison  (strychnin)  could  not  be  demonstrated  in 
the  lymph. 

Though  there  could  scarcely  remain  any  doubt,  after 
these  experiments,  that  indeed  the  blood-vessels  mediate 
almost  the  entire  absorption  of  substances  soluble  :n 
water  from  the  tissues  and  cavities  of  the  body,  lately 
my  assistant,  Dr.  Klapp  (in),  proved  this  conclusively. 
He  had  the  happy  idea  of  choosing  sugar  of  milk  for  ex- 
perimentation. Yoit  (112)  has' shown  that  every  particle 
of  sugar  of  milk  hypodermically  injected  in  any  desired 
place  is  excreted  by  and  can  be  found  in  the  urine.  Be- 
sides this  substance  can  be  easily  demonstrated  quantita- 


126  ABSORPTIVE   EFFECT   OF  HYPEREMIA 

tively  with  the  polarization  apparatus.  We  have,  there- 
fore, in  sugar  of  milk  a  substance  which  permits  exact 
quantitative  determination  of  the  extent  of  excretion  on 
account  of  which  experiments  of  absorption  reached 
an  hitherto  unknown  exactness. 

Klapp  ligated  in  dogs  the  ductus  thoracicus  and  the 
ductus  lymphaticus  dexter  and  thus  excluded  all  lymph 
channels  which  could  further  into  the  blood  sugar  of  milk 
injected  into  the  abdominal  quantity.  In  spite  of  this, 
the  sugar  of  milk  appeared  in  the  urine  in  the  same  time 
as  was  observed  in  the  same  animals  a  few  days  previous 
while  their  lymph  channels  were  normal.  Thus,  the  un- 
assailable proof  is  established  that  substances  soluble  in 
water  may  be  taken  up  by  the  circulation  solely.  Neither 
Klapp  nor  the  above-mentioned  experimenters  deny  that 
the  lymph  channels  too  may  participate  in  the  process  of 
absorption,  but  inasmuch  as  their  exclusion  quantitatively 
does  not  retard  absorption  they  evidently  play  but  an  un- 
important role  and  do  not  possess  the  importance  as  re- 
gards the  absorption  of  water,  salts  and  substances  solu- 
ble in  water  ascribed  to  them  in  the  famous  works  of  v. 
Recklinghausen  (113)  and  Wegner  (114).  On  the  other 
hand,  v.  Recklinghausen  has  just  as  conclusively  shown 
that  small  bodily  elements  (milk,  emulsions,  blood,  co- 
balt, Indian  ink)  are  taken  up  by  the  lymph  channels  of 
the  diaphragm.  These  observations  have  been  confirmed 
by  several  authorities.  Thus  Sulzer  (115)  found  kernels 
of  wheat  which  he  had  injected  into  the  abdominal 
cavity,  in  the  lymph  channels  on  the  chest  side  of  the 
diaphragm  and  in  the  thoracic  duct  and  believes  that  they 
get  there  without  any  medium,  being  but  partially  taken 
up  by  the  leucocytes  and  carried  off. 

Similar  results  were  reached  by  Muscatello  (116).  He 
found  that  the  diaphragm  is  the  only  part  of  the  serosa  of 
the  abdominal  cavity  intended  for  the  absorption  of 
granular  substances.  This  absorption  takes  place  with 
great  rapidity.  He  believes  that  fine  granular  substances 
and  some  pliant  bodies  pass  through  the  endothelial  cells 
in  a  free  condition,  while  rigid  bodies  are  carried  off,  as 
a  rule,  by  migratory  cells. 

We  can,  therefore,  pronounce  the  following  as  an 
axiom,  established  by  many  scientific  experiments :  The 


ABSORPTIVE  EFFECT  OF  HYPEREMIA        127 

absorption  of  water  and  substances  soluble  in  water  in 
Castro-intestinal  digestion  and  tissues  and  cavities  of  the 
body  takes  place  essentially  through  the  blood-vessels, 
the  absorption  of  the  smallest  bodily  elements,  on  'the 
other  hand,  essentially  through  the  lymph  vessels. 

For  us  practitioners  the  following  question  is  of  the 
greatest  importance:  Can  we  artificially  influence  this 
absorption,  as  I  have  already  asserted,  and  can  this 
influence,  tested  in  practice,  be  demonstrated  scientifi- 
cally? Alas,  as  I  have  shown,  we  know  so  little  about 
the  influence  of  the  lymph-current  that  the  question 
whether  we  can  aid  in  the  absorption  of  bodily  elements 
must  be  excluded  from  scientific  discussion.  We  are  for 
this  reason  limited  to  the  question:  How  does  the  influ- 
ence of  the  blood-current  affect  absorption? 

We  have  some  old  scientific  observations  on  this  sub- 
ject. During  the  era  of  venesection  the  influence  of  the 
general  volume  of  blood  on  absorption  was  thoroughly 
discussed.  As  this  is  of  no  concern  to  us  and  since  only 
the  later  contributions  show  a  local  influence  on  absorp- 
tion, I  will  at  once  refer  to  these.  When  v.  Esmarch's 
bloodlessness,  on  account  of  its  great  successes,  stirred 
the  minds  of  the  surgeons  the  advantages  and  disad- 
vantages offered  by  this  process  were  zealously  dis- 
cussed. To  that  time  belongs  a  publication  by 
Wolfler  (117),  in  which  it  is  intended  to  show  the  lack 
of  danger  from  strong  antiseptics  applied  to  wounds, 
the  locality  of  which  was  kept  bloodless.  Though  in- 
tended for  a  different  purpose,  this  publication  is  of 
great  interest  to  us  because  it  plainly  shows  an  influence 
of  hyperemia  on  absorption.  Wolfler  produced  a  wound 
at  the  ankle-joint  of  dogs,  dropped  on  it  3  grammes  of  a 
watery  solution  of  potash  ferro-cyanide  and  showed  that 
the  remedy  could  be  demonstrated  in  the  urine  only  after 
thirty  minutes.  If  he  made  bloodless  the  extremity  and 
applied  to  an  equally  large  wound  12  grammes  of  the  dye, 
as  long  as  the  bloodlessness  was  maintained  no  reaction 
appeared  in  the  urine ;  ten  minutes  after  removal  of  the 
bloodlessness  reaction  occurred  in  the  urine.  From  this 
Wolfler  concluded  that  the  absorption  of  the  dye  into 
the  circulation  takes  place  more  rapidly  after  removal 


128        ABSORPTIVE  EFFECT  OF  HYPEREMIA 

of  the  rubber  producing  bloodlessness  than  under  ordi- 
nary conditions. 

Wolfler  tries  to  meet  the  objection  that  during  the 
bloodlessness  the  dye  may  have  spread  below  the  rubber 
tubing  in  the  extremity  excluded  from  the  circulation  bv 
diffusion  and  osmosis  and  for  this  reason  enters  the  cir- 
,culation  more  rapidly  on  releasing  the  constriction,  by 
the  following  method :  He  applied  the  constricting  rub- 
ber in  the  inguinal  region  and  dropped  the  dye  on  the 
wound  at  the  ankle-joint.  After  thirty-five  minutes  he 
applied  a  second  piece  of  rubber  tubing  two  fingers  above 
the  wound  and  removed  the  first.  In  spite  of  this  no  re- 
action occurred  in  the  urine  in  the  usual  time.  But  after 
the  second  constriction  was  released  the  substance  was 
found  six  minutes  later  in  the  urine.  Wolfler  concludes 
that  below  the  constriction  no  imbibition  with  dye  takes 
place  in  the  extremity  excluded  from  the  circulation. 
Experiments  with  strychnin  led  to  the  same  re'sult. 

As  is  well  known,  there  occurs  after  artificial  blood- 
lessness an  enormous  arterial  (the  so-called  reaction) 
hyperemia.  Thus  we  have  an  example  that  arterial  hy- 
peremia  considerably  accelerates  the  absorption  of  a 
substance  soluble  in  water.  The  latter  appeared  in  the 
urine  in  from  six  to  ten  minutes,  though  this  lasts  thirty 
minutes  under  ordinary  conditions. 

Klapp  (118)  justly  offers  some  objections  against  the 
value  of  these  experiments.  He  thinks  that  it  is  contrary 
to  our  experience  on  diffusion,  osmosis  and  imbibition  to 
accept  that  the  applied  liquid  could  not  saturate  the  tis- 
sues in  the  vicinity  of  the  wound  without  the  blood-cur- 
rent and  cites  facts  which  prove  that  dissolved  substances 
spread  in  the  tissues  even  after  interruption  of  the  circula- 
tion. The  fact  that  Wolfler  after  applying  the  second  con- 
strictor two  fingers  above  the  wound  found  no  reaction  in 
the  urine  does  not  yet  prove  that  the  immediate  vicinity 
of  the  wound  was  not  thoroughly  saturated  with  the 
dye.  Klapp  further  calls  attention  to  the  fact  that  all 
experiments  in  absorption  with  dyes  and  poisons  are  un- 
certain because  they  can  be  demonstrated  only  qualita- 
tively by  phenomena  of  poisoning  and  reactions  but  never 
quantitatively.  It  was  this  that  led  him  to  the  above-men- 
tioned introduction  of  sugar  of  milk  for  the  purpose  of  ex- 


ABSORPTIVE  EFFECT  OF  HYPEREMIA         129 

perimenting  on  absorption,  as  this  substance  can  be  dem- 
onstrated quantitatively  at  any  period  of  the  experiment 
with  great  ease.  This  process  is  evidently  so  superior  to 
all  others  that  I  will  limit  myself  to  a  short  reproduction 
of  the  theories  made  by  Klapp  in  regard  to  the  influence 
on  absorption  by  agents  producing  hyperemia. 

Klapp  first  of  all  demonstrated  that  active  hyperemia 
produces  a  decided  acceleration  of  absorption.  He  in- 
jected sugar  of  milk  hypodermically  into  one  of  the  hind 
legs  of  dogs  and  then  placed  the  extremity  for  a  period  of 
twenty  minutes  to  two  hours  in  a  hot-air  apparatus.  He 
found  that  among  eighteen  experiments  in  two  instances 
insignificant  scarcely  noticeable  differences  became  evi- 
dent. In  the  rest  absorption  took  place  two  to  three 
times  faster.  From  experiments  which  Klapp  made  on 
himself  and  on  students  he  learned  that  hot  air  regularly 
produced  an  increase  of  absorption  but  in  a  less  degree 
than  that  observed  in  dogs.  Klapp  showed  in  another 
contribution  (119)  that  absorption  in  the  abdominal 
cavity  can  be  accelerated  by  hot  air.  Absorption  was 
always  present  but  not  as  considerably  as  when  the 
remedy  was  injected  in  the  leg  and  subjected  to  the  same 
conditions.  This  is  easily  understood,  for  the  hot  air 
has  an  entirely  different  effect  on  a  small  limb  than  on 
the  large  belly. 

It  could  be  said  against  the  value  of  these  experiments 
on  the  effectiveness  of  the  hyperemia,  that  they  are  unre- 
liable, as  the  employment  of  heat  produces  numerous 
changes  aside  from  the  hyperemia.  This  objection  seems 
justified  because  the  influence  of  heat  and  cold  on  absorp- 
tion has  been  demonstrated  long  ago.  Thus  Sassetzky 
(120)  observed  that  certain  drugs  (pilocarpin,  morphin, 
potash  of  iodide)  were  more  quickly  absorbed  by  the 
human  body  if  he  raised  the  temperature  of  the  skin  at 
the  place  of  injection  to  39°  C.  or  if  he  heated  the  solu- 
tions ;  on  reducing  the  same  place  to  a  temperature 
of  12°  by  freezing  agents  absorption  was  slower,  the 
drugs  appearing  in  the  urine  three  or  four  minutes  later 
than  if  the  former  method  was  employed. 

v.  Kossa  (121),  basing  on  the  earlier  experiments 
of  Luchsinger  and  Claude  Bernard,  made  the  follow- 
ing experiments  :  He  injected  into  the  auricles  of  rabbits, 


130         ABSORPTIVE  EFFECT  OF  HYPEREMIA 

which  he  cooled  with  freezing-  agents  of  cold  water  (hy- 
drant water  at  +  7°  _C.  suffices),  the  strongest  poisons, 
potassium  cyanide,  strychnin,  picrotoxin.  All  these 
animals  remained  alive  and  well  if  the  auricle  was  kept 
cool  one  to  one  and  one-half  hours,  while  the  other  ani- 
mals either  died  or  had  to  pass  through  the  most  intense 
forms  of  poisoning.  He  believes  that  during  the  effect 
of  cold  absorption  takes  place  either  not  at  all  or  at 
least  so  slowly  that  the  drug  is  gradually  excreted  with- 
out producing  phenomena  of  poisoning. 

Klapp,  too,  could  considerably  retard  the  excretion  of 
sugar  of  milk  which  he  had  injected  into  the  tissues  and 
into  the  abdominal  cavity  if  he  produced  cooling  by  ice- 
water  or  with  the  ice-bag. 

We  know  that  warmth  produces  hyperemia  and,  ac- 
cording to  my  conception,  arterial  hyperemia,  while  cold 
produces  anemia  or,  if  applied  for  a  long  while,  stasis 
hyperemia.  These  experiments,  therefore,  are  in  accord 
with  our  view  that  arterial  hyperemia  accelerates  ab- 
sorption, while  anemia  retards  it.  Several  other  inter- 
esting experiments  of  Klapp  confirm  this  view.  He 
found  that  wide  opening  of  the  abdominal  cavity  and 
short  forward  displacement  of  the  intestines — up  to 
fifteen  minutes — accelerates  absorption  in  the  abdominal 
cavity,  and  that  this  is  retarded  after  prolonged  displace- 
ment. We  know  from  numerous  observations  that  a 
large  abdominal  incision  and  forward  displacement  of 
the  intestines  produces  intense  hyperemia  in  the  latter. 
At  first  the  hyperemia  is  an  active  one ;  later,  in  conse- 
quence of  dehydration,  cooling  off  and  other  injuries — 
passive.  According  to  Hildebrandt  (122),  the  active  hy- 
peremia lasts  in  rabbits  about  twenty  minutes  when  it 
changes  to  the  passive  form.  This  fully  agrees  with 
Klapp's  results  and  we  again  see  that  active  hyperemia 
accelerates  absorption  although  so  major  an  experiment 
as  is  abdominal  section  and  displacement  of  the  viscera 
in  itself  necessarily  produces  an  injury  of  the  tissues  of 
the  abdominal  cavity. 

At  first  it  seemed  strange  to  me  how  Klapp's  finding 
that  elevated  position  of  an  extremity  retards  absorption, 
for  we  know  from  numerous  experiments  that  edema 
disappears  in  such  a  condition.  In  healthy  extremities 


ABSORPTIVE   EFFECT  OF  HYPEREMIA  131 

the  retardation  of  absorption  of  sugar  of  milk  by  that 
method  could  be  established  without  any  doubt  and  we 
will  not  be  amiss  if  we  will  ascribe  this  to  the  lessened 
volume  of  blood  produced  by  the  high  posture.  We, 
therefore,  see  that  the  scientific  experiment  confirms  our 
view,  gained  from  practical  experience,  that  arterial  hy- 
peremia  favors  absorption. 

On  the  other  hand,  considered  from  a  purely  theoretic 
standpoint,  it  seems  reasonable  to  accept  that  a  stasis 
bandage  during  its  activity  diminishes  absorption.  These 
thoughts  have  caused  us  to  combine  stasis  hyperemia 
\vith  massage,  when  used  in  non-infectious  diseases  for 
the  removal  of  stiffened  joints  due  to  rheumatism  and 
pther  causes,  in  the  hope  of  producing  absorption  of 
morbid  material  which  the  hyperemia  has  softened  and 
dissolved  (see  subsequent  chapter). 

Klapp  has  undertaken  to  solve  the  question  by  experi- 
ment. He,  indeed,  found  that  as  long  as  the  stasis  band- 
age was  applied  absorption  was  considerably  retarded 
and  increased  again  on  removal  of  the  bandage.  The 
increase  of  absorption  after  removal  of  the  bandage  was 
so  considerable  that  the  final  result  of  the  stasis  hyper- 
emia really  meant  acceleration.  But  it  must  be  remem- 
bered that  Klapp  applied  stasis  hyperemia  for  only  one 
hour  after  the  injection  of  the  sugar  of  milk  and  that  the 
total  excretion  was  completed  in  three  hours.  We,  how- 
ever, apply  stasis  hyperemia  to  diseased  extremities  for 
longer  periods  and  we  may  accept  that  the  final  result  is 
not  an  acceleration  of  absorption.  For  this  reason  we 
have  added  massage  in  such  cases. 

Another  assistant  of  mine,  Dr.  Ritter,  has  earlier  dem- 
onstrated the  retarding  effect  of  the  stasis  bandage  on 
absorption.  He  injected  tuberculin  in  tuberculous  ex- 
tremities, which  were  under  the  influence  of  an  intense 
stasis  hyperemia.  He  succeeded  in  the  majority  of  cases 
in  withholding  for  a  considerable  time  the  reaction  of 
the  tuberculin. 

I  have  repeatedly  called  attention  to  the  fact  that  water 
and  substances  soluble  in  water  normally  are  almost  en- 
tirely absorbed  through  the  blood,  but  that  this  does 
not  mean  that  the  lymph-current  could  not  do  this ;  in 
fact,  the  latter  seems  to  be  the  case,  for  instance,  in 


132  ABSORPTIVE   EFFECT  OF  HYPEREMIA 

Volkmann's  treatment  of  chronic  articular  effusion  with 
powerful  compression  bandages.  Volkmann  himself  de- 
scribes that  the  bandages  were  so  forcibly  wound  over 
the  swollen  joint  that  the  part  of  the  extremity  below  it 
became  edematous  and  blue.  The  process  is  for  this 
reason  so  painful  that  the  patient  does  not  sleep  during 
the  first  night  and  frequently  also  during  the  second. 
Inasmuch  as  so  firm  a  pressure  renders  anemic  the  entire 
reg;on  of  the  affected  joint  corresponding  to  the  width  of 
the  bandage,  it  is  probable  that  the  effusion  is  forced  into 
the  lymph  spaces  of  the  joint  and  carried  off  by  the 
lymph  channels. 

On  the  other  hand,  it  seems  that  the  lymph  channels 
can  be  replaced  by  the  blood  channels  in  the  absorption 
and  removal  of  excreted  lymph.  For  we  surgeons  often 
extensively  destroy  the  large  lymph  trunks  when  cleaning 
out  diseased  axillary  and  inguinal  glands,  because  we 
remove  the  region  all  glands  and  connective  tissue, 
leaving  only  the  larger  b'lood-vessels  and  nerves.  After 
such  extensive  operations  we  see  comparatively 'seldom 
lymph-stasis,  and  we  must  assume  that  the  excreted 
lymph  is  taken  up  by  the  blood-vessels  until  sufficient  col- 
lateral lymph  channels  have  formed.  If  this  does  not 
occur  it  seems  that  the  blood-vessels  can  not  always  take 
care  of  the  excreted  lymph,  for  a  number  of  cases  are 
known  in  which,  after  such  operations,  lasting  edema  and 
elephantiasis  developed, 


CHAPTER  XV 

SOLVENT  EFFECT  OF  HYPEREMIA 

In  the  diseases  against  which  experience  has  shown  the 
agents  producing  hyperemia  to  be  useful,  we  have  not 
always  to  deal  with  aqueous  substances  or  such  as  are 
soluble  in  water,  but  generally  with  solid  substances, 
such  as  blood-clots,  granulations  in  joints  and  stiff  joints. 
If  we  want  to  cause  their  absorption  they  first  must 
be  dissolved  and  there  can  be  no  doubt  that  the  hyper- 
emia is  able  to  accomplish  it.  Under  its  influence  we 
occasionally  observe  the  disappearance  of  arthritic  granu- 
lations and  nodules  in  tendons  in  a  comparatively  short 
while.  Among  others,  I  had  the  opportunity  of  nicely 
observing  it  in  a  man  whose  diverse  joints  and  tendon 
sheaths  were  in  a  hopeless  condition  due  to  an  attack 
of  gonorrheal  rheumatism  which  he  passed  some  time 
ago.  He  had  been  treated  for  a  long  time  without  any 
success  with  all  sorts  of  mild  remedies  (massage,  water, 
iodine  application)  and  with  energetic,  torturing  methods 
(medico-mechanic  machines,  brisement  force  with  and 
without  anesthesia),  but  never  with  agents  producing 
intense  hyperemia.  On  the  extensor  tendons  of  his 
fingers  remained  nodules  perceptible  to  sight  and  touch, 
which  enabled  us  to  become  thoroughly  convinced  in 
regard  to  the  solvent  effect  of  hyperemia.  In  order  to 
study  both  kinds,  I  first  applied  on  one  side  stasis  hyper- 
emia, then  hot  air  on  the  other.  During  the  application 
of  each  form  I  could  observe  how  the  nodules  shrunk 
and  disappeared.  In  a  similar  manner  I  saw  some  years 
ago  how  a  nodule  in  a  joint,  perceptible  to  sight  and 
touch,  disappeared  under  the  influence  of  the  suction 
apparatus.  '  The  most  striking  effect  of  the  hyperemia 
could  be  noticed  in  the  first  few  applications ;  later  the 
solution  proceeded  less  rapidly. 

As  far  as  the  fact  of  the  solution  of  morbid,  solid  sub- 
stances by  hyperemia  is  concerned,  there  can  be  no 
doubt  about  it  after  these  observations.  I  remind  that 
since  ages  the  so-called  skin  irritants  and  "derivative"  » 
agents,  or,  as  we  assert,  also  agents  for  the  production 
of  hyperemia,  have  been  utilized  for  the  purpose  of 

133 


134         SOLVENT  EFFECT  OF  HYPEREMIA 

solution.  For  this  reason  they  have  fittingly  also  been 
called  softening  and  dividing  remedies.  In  the  following 
I  intend  to  discuss  these  facts  more  fully,  not  so  much  to 
confirm  them  as  to  depict  the  effective  causes  of  the  solu- 
tion in  accordance  with  our  present  knowledge. 

It  is  undisputed  that  inflammation  and  especially  sup- 
purative  inflammation  has  a  tissue  solvent  and  melting 
effect.  This  is  attributed  principally  to  the  pus  corpus- 
cles. The  above  described  uniform  effects  of  pure  hy- 
peremia, however,  plainly  speak  for  it  that  the  inflam- 
matory hyperemia  too  plays  a  role.  The  following  expe- 
rience seems  to  confirm  this :  No  one  will  think  of 
attributing  the  dilatation  of  the  urethral  strictures  with 
sounds  to  their  mechanical  effect  only.  It  is  generally 
admitted  that  the  inflammation  produced  by  the  irritation 
of  the  scar  softens  the  latter  and  makes  it  more  yielding, 
and,  following  our  views  now  prevailing,  this  is  accom- 
plished solely  by  the  pus  corpuscles.  To  oppose  this, 
I  point  to  the  fact  that  scars  (strictures)  of  the  vagina, 
which  if  left  unchanged  would  prove  an  obstacle  to 
delivery,  during  pregnancy  become  so  soft  that  they 
acquire  an  elasticity  enabling  birth  to  take  place  without 
difficulty.  Here  there  can  be  no  question  of  suppura- 
tion and  only  the  intense  hyperemia  which  prevails  in 
all  parts  of  the  genital  apparatus  during  pregnancy  can 
have  produced  the  solvent  effect. 

Even  Billroth  (123),  in  his  treatise  on  inflammation, 
ascribes  its  solvent  effect  principally  to  the  immigrated 
leucocytes.  He  says :  "Every  physician  knows  that  the 
firm  connective  tissue,  infiltrated  by  inflammation,  may 
totally  disappear  and  become  dissolved  in  the  process  of 
suppuration ;  it  is  furthermore  known  that  even  cartilage 
and  bone  in  inflammation  may  become  changed  into 
soluble  substances  and  that  tendons,  nails  and  hairs  only 
energetically  resist  this  process  of  dissolution,  the  former 
being  expelled  as  necrotic  shreds  during  suppuration." 
He  demonstrates  on  specimens  of  inflamed  prepuces  how 
the  inflammatory  edema  and  immigrated  cells  totally  dis- 
solve the  connective  tissue.  He  ascribes  this  effect  to  the 
cells  for  he  says:  "It  seems  to  follow  from  the  cited  ob- 
servations that  one  of  the  effects  of  living  cells  is  their 
ability  under  certain  conditions  to  transform  the  fibers 


SOLVENT  EFFECT  OF  HYPEREMIA         135 

of  connective  tissue  and  also  the  fibrin  fibers  into  a  soft, 
semi-gelatinous  consistence." 

We  saw  from  the  above-cited  unobjectionable  observa- 
tions that  a  solution  of  connective  tissue  is  possible  by 
hyperemia  alone.  •  We,  therefore,  can  not  help  but  state 
that  the  view  that  the  suppurative  process  in  inflamma- 
tion only  accomplishes  the  solution  is  one-sided  and  we 
must  ascribe  an  important  role  to  the  hyperemia  accom- 
panying the  inflammation  during  its  course.  I  do  not 
mean  thereby  to  doubt  the  solvent  and  digestive  effect 
of  suppuration  established  by  numerous  observations. 
This  effect  has  been  ascribed  for  a  long  time  to  a  diges- 
tive property  of  the  pus  corpuscles ;  these  are  said  to 
excrete  so-called  digestive  enzymes  which  accomplish 
the  melting.  It  was  principally  Leber  (124).  who  has 
aided  this  view  to  victory  by  his  beautiful  and  convinc- 
ing experiments.  But  numerous  other  experiments, 
which  we  can  not  cite  here,  have  positively  established 
the  digestive  and  solvent  effect  of  the  leucocytes. 

Recently  Buchner  (125)  has  ascribed  to  all  cells  of  the 
body,  in  addition  to  constructive  (assimilating),  decon- 
structive  (disassimilating)  substances.  The  latter  are 
said  to  be  given  by  the  cells  as  solvent  digestive  juices 
(enzymes)  to  the  blood-serum,  which  assumes  the  same 
effect,  while  the  constructive  substances  remain  in  the 
cells.  According  to  Buchner,  these  digestive  juices  dis- 
solve everything  foreign  that  has  entered  the  body,  that 
is  to  say,  not  only  organic  foreign  bodies,  catgut  threads, 
necrosed  tissue,  but  also  bacteria. 

He  holds  to  his  view  of  the  bactericidal  property  of  the 
blood-serum,  the  effective  components  of  which  come 
from  the  leucocytes,  but  does  not  believe  that  this  is  a 
specific  activity  but  that  the  effect  of  the  blood-serum 
as  regards  the  dissolution  of  everything  foreign  em- 
braces also  the  bacteria,  thus  causing  their  destruction. 

Buchner  represents  views  which  Landois  (126)  long 
ago  has  expressed,  though  not  so  extensively.  This 
author  first  showed  that  6very  species  has  a  blood  of 
its  own  which  it  tries  to  keep  clean  from  foreign  com- 
ponents under  any  and  all  circumstances.  For  this  rea- 
son any  kind  of  foreign  blood  which  is  added  to  that  of 
an  animal  or  man  is  at  once  destroyed  by  the  blood  of 


136          SOLVENT  EFFECT  OF  HYPEREMIA 

the  receiver.  Landois  convincingly  demonstrated  that 
the  blood-serum  of  every  animal  causes  dissolution  of  the 
blood  corpuscles  from  any  different  species.  Recent  bac- 
teriologic  research,  which  ignores  these  investigations, 
has  fully  confirmed  these  observations  and  more  ex- 
tensively utilized  them  in  an  entirely  new  direction. 

The  improvement  of  stiffened  joints,  which  follows 
after  the  application  of  either  active  or  passive  hyper- 
emia, must  first  of  all  be  ascribed  to  the  solvent  proper- 
ties of  the  blood.  Certainly  a  good  many  other  things 
must  be  taken  into  consideration.  In  all  probability  con- 
nective tissue  adhesions  become  softer,  more  pliable  and 
elastic  in  consequence  of  serous  saturation  and  swelling. 
I  have  already  repeatedly  shown  that  a  great  portion  In 
the  removal  of  stiff  joint  is  due  to  the  relief  of  pain 
produced  by  the  hyperemia.  For  otherwise  it  were  not 
imaginable  how  a  man  could  move  his  joint,  afflicted 
with  chronic  rheumatism,  after  an  hour's  treatment  in 
the  hot-air  apparatus,  or  a  gonorrhoic  his  furiously  pain- 
ful, completely  immovable  inflamed  joint,  after  an  hour's 
application  of  stasis  hyperemia. 

Of  late  Sudeck  (127)  has  tried  to  explain  the  favorable 
effect  of  stasis  hyperemia  on  joints  stiffened  by  trauma 
by  an  improvement  in  the  nutrition  of  the  bone,  which 
he  has  demonstrated  to  be  atrophic ;  (for  details,  see  fur- 
ther). It  is  possible,  though  not  proven,  that  this,  too, 
plays  a  role,  but  we  can  not  overlook  the  dissolving 
effect  of  the  blood,  which  is  proved  by  the  disappearance 
of  the  tendon  and  articular  nodules  above  described  and 
directly  observed  by  us. 

We  must  never  forget  that  the  name  hyperemia  means 
a  large  series  of  chemical  and  physical  processes,  and 
the  greater  the  experience  which  I  am  gaining  in  this 
direction  the  more  do  I  turn  from  the  one-sided  views 
here  represented  by  Sudeck  and,  as  already  mentioned, 
in  a  somewhat  different  direction  also  by  bacteriologists. 
For  that  matter,  I  can  not  take  friendly  to  the  scheme,  so 
prevalent  in  modern  pathology,  which  ascribes  the  sole 
efficiency  to  only  one  of  the  many  properties  or  sub- 
stances of  life  processes.  For  if  we  carefully  look  upon 
the  physiological  processes  in  the  body  we  notice  that 
they  have  a  multitude  of  purposes  which  point  to  one 


SOLVENT   EFFECT   OF   HYPEREMIA  137 

final  purpose.  For  this  many  examples  can  be  cited  ; 
since  we  are  here  interested  in  the  effect  of  hyperemia  I 
will  choose  two  forms  of  physiological  hyperemia  as 
examples,  though  more  striking  proofs  can  be  found  in 
other  departments. 

If  we  subject  a  part  of  the  body  to  intensely  hot  air, 
it  becomes  vigorously  hyperemic,  and  if  the  part  was 
large,  other  parts  of  the  body  experience  the  same 
change.  This  hyperemia  serves  different  purposes.  It 
must  give  off  the  material  for  perspiration  and  cool 
the  intense  and  rapidly  flowing  blood-current  traversing 
the  endangered  part  and  finally  reduce  the  temperature 
in  the  entire  body  as  the  blood  is  led  towards  the  peri- 
pheral parts,  there  giving  off  the  warmth  which  it  has 
taken  up.  The  hyperemia,  therefore,  fulfills  at  least  three 
different  missions,  viz.,  it  took  up  warmth  at  one  place, 
gave  it  off  at  another  and  made  possible  the  pronounced 
perspiration,  but  all  these  again  served  one  ultimate  end : 
to  protect  the  body  against  local  and  general  overheat- 
ing. Intense  hyperemia  makes  possible  the  excretion  of 
water  after  consumption  of  a  good  quantity  of  food,  the 
separation  of  variable  digestive  juices  in  the  gastro-in- 
testinal  canal  and  finally  resorption.  And  all  these  vari- 
ous processes  again  have  but  one  general  aim  :  the  assimi- 
lation of  food. 

Nothing  can  prove  better  th'e  entirely  different  effect 
of  artificial  hyperemia  on  diseases  than  this  idea :  One 
of  the  recognized  effects  of  stasis  hyperemia  is  the  forma- 
tion of  new  bone.  For  this  reason  it  is  used  to  knit 
fractures  of  bones  which  do  not  want  to  heal.  This  very 
hyperemia,  nevertheless,  does  not  permit  the  ends  of 
joints  suffering  from  large  ulcers  and  caries  to  become 
ankylosed  but,  as  numerous  observations  have  convinced 
me,  keeps  the  joint  mobile  which  otherwise  would  cer- 
tainly have  become  locked.  Both  active  and  passive 
hyperemia  act  equally  in  the  dissolution  of  stiff  joint. 
More  details  will  be  given  in  the  concerned  chapter  in 
the  special  part. 

Probably  the  solvent  process  of  hyperemia  changes  the 
greater  part  of  the  diseased  granulations  and  adhesions 
of  stiffened  joints  into  substances  soluble  in  water,  which 
is  absorbed  by  the  blood.  But  it  can  scarcely  be  doubted 


138         SOLVENT  EFFECT  OF  HYPEREMIA 

that  there  still  remain  tissue  particles  which  are  carried 
off  by  the  lymph  channels.  It  is  therefore  desirable  that 
our  knowledge  about  the  influence  of  .hyperemia  on  the 
lymph-current  become  more  thorough.  As  long  as  we 
know  so  little  about  these  conditions,  it  is  useless  to 
establish  assertions  and  assumptions  that  even  in  this 
direction  our  practical  experience  is  supported  and  ex- 
plained by  scientific  recognition. 


CHAPTER  XVI 

NUTRITIVE  EFFECT  OF  HYPEREMIA 

In  the  discussion  of  the  preceding  chapters  we  were 
in  the  pleasing  situation  of  treating  matters  of  every-day 
experience.  As  for  myself,  I  have  not  the  least  doubt 
that  arterial  and  venous  hyperemia  relieve  pain ;  that 
both  are  solvents ;  that  arterial  hyperemia  absorbs,  and 
that  passive  hyperemia  cures  infectious  diseases,  for 
I  have  seen  this  with  my  own  eyes  innumerable  times. 
I  could  have  described  each  of  these  facts  with  a  few 
words,  they  requiring  no  further  proof.  Nevertheless,  I 
brought  lengthy  discussions  in  order  to  explain  those 
effects  from  the  standpoint  of  our  scientific  views  of  to- 
day and  to  bring  them  in  harmony  with  foreign  obser- 
vations. Fortunately  it  was  possible  to  accomplish  the 
latter ;  those  facts,  however,  have  been  so  positively 
established  that,  were  the  opposite  the  case,  I  still  would 
have  adhered  to  them  to  the  fullest  extent.  I  express 
myself  decidedly,  though  my  observations  have  received 
but  little  confirmation  (if  any)  from  others.  For  the 
properties  of  artificial  hyperemia  claimed  by  me  in  the 
preceding  chapters  are  so  striking  that  I  would  be  a 
poor  observer  indeed  had  I  been  mistaken  in  them. 

Conditions  are  entirely  different  in  this  chapter,  which 
treats  of  the  influence  of  nutrition  by  hyperemia.  For 
although  in  the  discussion  of  the  effect  of  hyperemia,  this 
question  has  been  thoroughly  and  frequently  considered 
in  a  manner  directly  opposite  to  my  more  recent 
observations,  conditions  are  by  no  means  clear.  We 
will  see  that  here  the  views  are  very  contradictory. 

The  assertion  that  hyperemia  as  such  has  a  nutritive 
effect  is  very  old.  First  of  all,  this  has  been  claimed  for 
the  so-called  functional  hypertrophy.  It  was  believed 
that  the  increased  function  produces  hyperemia  and  this 
in  turn  hypertrophy.  I  do  not  want  to  enter  into  this 
old  quarrel.  On  the  whole,  it  must  be  considered  as 
decided  that  hyperemia  is  necessary  for  hypertrophy  but 
that  it  is  not  the  essential  cause,  but  that  the  so-called 
functional  irritation— a  word  for  an  as  yet  unknown 
conception — causes  and  enables  the  cells  to  take  up  sub- 

139 


140  NUTRITIVE   EFFECT   OF   HYPEREMIA 

stances  from  the  excessive  nutrition  offered  by  the  hy- 
peremia,  which  they  utilize  for  their  increase  or  diminu' 
tion.  Inasmuch  as  we  always  have  in  view  the  practical 
aim  to  cure  diseases  with  the  hyperemias,  we  will  limit 
ourselves  to  the  question :  Can  we  succeed  in  passively 
feeding  through  hyperemia  weak,  withered  and  unde- 
veloped parts  of  the  body  to  such  an  extent  that  they 
increase  their  utility  (this  being  decisive)  and  circum- 
ference? 

In  my  opinion  two  things  must  here  be  kept  strictly 
separated,  viz. : 

1.  Can   we   bring  our   completed   bodily   tissues   in   a 
state  of  hyper-nutrition  through  hyperemia ;  can  we,  as  it 
were,  artificially  fatten  them  and  can  we  by  this  means 
influence  the  physiologic  growth? 

2.  Can    we    accelerate    or    incite    the    regeneration    of 
tissue  by  hyperemia? 

INFLUENCE    OF    HYPEREMIA    ON    THE     NUTRITION    OF     COM- 
PLETED  PARTS   OF   THE    BODY   AND   ON 
PHYSIOLOGIC    GROWTH 

Many  of  the  older  observations  on  the  causes  and  ex- 
istence of  hypertfophic  bodily  parts  can  not  be  utilized 
because  all  possible  things  have  been  designated  by  the 
one  term  "giant-growth,"  of  which  we  now  know  that 
they  owe  their  origin  to  diverse  etiologic  factors.  Thus, 
for  instance,  diseases  which  we  now  would  classify  as 
syringomyelia,  acromegaly  and  the  first  degrees  of  di- 
verse forms  of  muscular  atrophy  have  been  regarded  as 
pure  hypertrophy  of  bodily  parts.  We  will,  therefore, 
have  to  be  careful  in  the  selection  of  cases,  accepting  only 
those  in  which  surely,  or  at  least  quite  likely,  hyper- 
emia was  the  real  cause-  of  the  hypertrophy  of  tissues 
and  bodily  parts.  It  has  been  asserted  that  muscular 
atrophy  has  been  observed  after  venous  hyperemia,  es- 
pecially as  a  consequence  of  venous  thrombosis.  Though 
these  cases  frequently  have  been  confused  with  muscular 
affections  of  a  different  character,  namely,  with  pseudo- 
hypertrophy  of  the  muscles  (lipomatous  hypertrophy  of 
muscles,  juvenile  progressive  muscular  atrophy  and  mus- 
cular affections  of  spinal  origin)  yet  there  are  several 
evidently  pure  cases  in  which  nothing  else  but  a  venous 


NUTRITIVE  EFFECT  OF  HYPEREMIA         141 

thrombosis  could  be  demonstrated  as  the  cause  of  the 
muscular  hypertrophy.  The  fact  that  the  affection  was 
limited  to  the  domain  of  venous  stasis  proves  that  this 
was  indeed  the  sole  cause.  The  individual  cases  are  so 
closely  alike  and  of  such  decisive  importance  to  our 
question  that  we  will  consider  them  in  detail. 

Paget  (128)  reports  a  case  of  hypertrophy  of  one  arm 
after  venous  thrombosis  The  affected  arm  was  almost 
one-third  larger  than  the  healthy  one  and  this  princi- 
pally due  to  a  greater  development  of  the  muscles  rather 
than  to  a  deep  edema.  The  adjoining  shoulder  and  the 
upper  part  of  the  pectoralis  major  muscle  were  strikingly 
large  and  wide.  In  connection  with  this  case  Paget 
mentions  an  observation  made  by  Professor  Laurie  on 
himself:  This  gentleman  became  afflicted  with  venous 
thrombosis  of  one  leg  as  a  sequela  to  typhoid  fever, 
which  produced  edema  and  thickening  of  the  muscles 
for  the  rest  of  his  life. 

The  following  cases  have  been  observed  and  described 
in  detail.  The  age  of  the  patients  at  the  time  of  the 
attack  of  venous  thrombosis  was  19,  20,  22,  26,  26,  29 
and  41  years;  most  of  them  were  several  years  older 
when  the  hypertrophy  was  observed.  Berger  (129)  re- 
ports three  cases  which  concern  the  leg:- 

Case  i.  The  affection  developed  from  venous  throm- 
bosis during  typhoid  fever.  The  left  leg  was  very  much 
thickened,  the  relief  of  the  quadriceps  glutei  and  triceps 
surae  muscles  were  considerably  arched  forward.  The 
foot  was  in  the  position  of  tip-foot.  The  skin  of  the 
affected  limb  was  traversed  by  numerous  dilated  super- 
ficial veins ;  the  surface  temperature  of  both  extremities 
was  alike.  The  thickened  musculature  felt  firm,  hard  and 
tense.  Skin  and  bones  were  not  noticeably  thickened. 
There  was  no  edema.  Sensibility  and  reflex-irritability 
were  greatly  diminished  throughout  the  entire  leg.  The 
patient  easily  tired  in  the  affected  limb,  whose  strength 
was  greatly  diminished.  Muscular  twitching  frequently 
occurred  after  exercise.  Electrical  irritability  was  greatly 
diminished. 

Berger  took  particles  from  symmetric  places  of  the 
soleus  muscle  of  each  leg  by  means  of  Middeldorpf's 
harpoon  for  microscopic  examination.  There  was  a  de- 


142         NUTRITIVE  EFFECT  OF  HYPEREMIA 

cided  difference  on  macroscopic  inspection.  The  muscle 
of  the  affected  limb  was  pale  and  anemic ;  that  of  the 
healthy  one  had  the  normal  deep,  red  color.  Micro- 
scopically a  true  hypertrophy  of  the  diseased  muscle 
was  established,  the  fibers  being  more  than  double  the 
normal  size.  Otherwise  they  were  of  normal  character. 
There  was  no  trace  of  interstitial  fat  or  connective  tissue 
granulation. 

Case  2..  Here,  too,  the  disease  was  due  to  venous  throm- 
bosis in  consequence  of  typhoid  fever,  and  affected  the 
left  leg.  The  patient  complained  of  pains,  muscular 
twitchings  and  weakness  in  the  diseased  limb.  This  had 
a  "truly  Herculean  musculature"  which  enlarged  it  con- 
siderably, while  the  skin  could  scarcely  be  designated 
as  hypertrophic ;  the  bone  was  normal.  On  the  dorsal 
side  of  the  foot  only  was  edema,  otherwise  the  enlarge- 
ment was  due  to  the  muscular  swelling.  The  limb  was 
very  weak,  muscular  force,  electrical  irritability  and 
sensibility  were  greatly  diminished. 

Examination  of  particles  of  muscle  removed  in  a  man- 
ner described  in  the  former  case  gave  the  same  result 
as  in  Case  i. 

Case  3.  The  disease  was  due  to  a  gunshot  wound  of  the 
thigh,  which,  according  to  the  history  of  the  case,  prob- 
ably was  followed  by  venous  thrombosis.  There  was 
enlargement  of  the  left  calf  wrhich  was  due  to  the  muscles, 
as  the  skin  and  bones  were  not  swollen.  Nowhere  was 
edema  to  be  observed,  the  venous  net  of  the  calf  was 
moderately  dilated.  The  rest  of  the  examination  showed 
a  condition  equal  to  that  in  the  two  former  cases.  An 
anatomical  examination  of  muscular  particles  was  not 
made. 

Lesage  (130)  tells  of  a  man  who  suffered  from  ;\ 
thrombosis  of  the  left  femoral  vein  during  an  attack  of 
typhoid  fever.  Lesage  saw  the  patient  two  years  after 
this  event  and  noted  the  following:  The  entire  left 
leg  was  much  larger  than  the  right  one.  The  hypertro- 
phy was  limited  to  the  musculature  and  was  largest  in 
the  calf.  Edema  and  varicosities  were  absent.  Bones 
and  skin  were  not  thickened.  Electrical  irritability,  re- 
flexes and  sensibility  were  normal,  -the  surface  tempera- 
ture of  the  affected  limb  was  elevated. 


NUTRITIVE   EFFECT  OF   HYPEREMIA  143 

At  the  end  of  the  day  some  edema  appeared  at  the 
foot  and  malleoli  and  a  slight  bluish  discoloration  of 
the  skin.  The  muscular  force  of  the  diseased  leg  was 
stronger  than  that  of  the  healthy  one,  the  former,  never- 
theless, tiring  much  quicker  when  muscular  spasms  ap- 
peared in  it.  The  muscles  of  the  diseased  limb  were 
softer.  Two  years  later  Lesage  found  the  same  condi- 
tion, the  disease,  therefore,  remaining  stationary. 

The  case  reported  by  Eulenburg  (131)  concerns  a 
man  who  also  suffered  from  thrombosis  of  the  left  femoral 
vein  in"  connection  with  a  grave  septic  affection.  A  year 
before  he  had  sustained  a  fracture  of  the  vertebrae,  which 
was  followed  by  decided  disturbances  of  innervation. 
Following  the  thrombosis  was  an  immense  hypertrophy 
and  weakness  of  the  muscles  of  the  left  leg.  The  ex- 
amination of  particles  of  muscle  taken  from  symmetrical 
places  of  both  legs  showed  muscular  degeneration  on 
both  sides  (the  right  leg  was  atrophic  owing  to  the  dis- 
turbance of  innervation  accompanying  the  fracture  of 
the  vertebrae),  but  on  the  left  side  "the  degenerated 
fibers  were  much  more  numerous  and  thicker.  They 
appeared  swollen,  though  the  dissection  was  alike.  The 
fatty  and  waxy  degeneration  is  pronounced ;  there  are 
also  less  normal  fibers.  The  interstitial  fat  infiltration 
shows  characteristic  series  as  found  in  pseudo-hypertro- 
phy of  muscles." 

Goldscheider  (132)  presented  a  young  man  with  hy- 
pertrophy of  one  leg  due  to  thrombosis  of  the  femoral 
vein  accompanying  a  traumatic  orchitis.  This  case  was 
described  in  detail  by  Masskow  (133).  This  case  is  of 
especial  interest  because  its  entire  course  was  observed 
by  Goldscheider.  The  patient  was  attacked  by  the 
thrombosis  in  1894  and  suffered  in  addition  from  violent 
twitching  of  the  muscles.  In  1897  the  leg  had  the  follow- 
ing appearance :  The  left  saphenous  vein  and  a  vein  on 
the  left  side  of  the  abdominal  skin  were  dilated,  the 
calf  shows  some  edema  and  cyanosis.  The  muscula- 
ture of  the  left  leg  and  especially  of  the  calf  is  decidedly 
hypertrophic  and  feels  harder  than  that  of  its  neighbor. 
Its  strength  is  weaker.  The  subcutaneous  fat  is  moder- 
ately increased  in  the  left  calf.  The  left  leg  perspires 
more  than  the  right  and  feels  warmer  but  cools  off 


144         NUTRITIVE  EFFECT  OF  HYPEREMIA 

quicker  and  has  less  hair.  The  hypertrophic  limb  is 
weaker  and  tires  easily.  Sensibility  is  not  disturbed. 
Electrical  irritability  of  the  muscles  of  the  left  calf  is 
diminished.  There  exist  muscular  contractions,  which 
occur  about  three  or  four  times  per  second.  On  exer- 
tion of  the  affected  limb  cramp-like  pains  develop.  An 
anatomical  examination  of  the  hypertrophic  muscles  was 
not  made. 

While  in  all  these  cases  the  increase  in  volume  of  the 
extremities  was  positively  due  to  a  venous  thrombosis, 
this  etiologic  factor  is  in  all  probability  also  the*  cause 
in  the  two  following  cases,  for  which  reason  it  may 
be  permissible  to  add  them  to  this  group. 

Auerbach  (134),  in  an  exhaustive  contribution,  re- 
ports the  following  case:  A  man,  twenty-four  years 
old,  noticed  on  undressing  that  his  right  arm  was  larger 
than  the  left  one ;  gradually  weakness  and  rapid  tiring 
appeared  in  the  affected  limb.  The  skin  showed  ex- 
tensive venous  nets  and  a  bluish,  marbled  appearance. 
The  right  hand  was  cooler  than  the  left.  After  a  pro- 
longed stay  in  the  air  it  became  dark  blue. 

Auerbach  excised  particles  from  the  deltoid  and  bi- 
ceps muscles  of. the  affected  and  from  the  biceps  of  the 
healthy. .limb  for  the  purpose  of  comparison  by  micro- 
scopic examination.  He  found  that  the  case  was  one  of 
true  muscular  hypertrophy.  This  was  due  to  a  decided 
expansion  of  the  muscular  cylinder..  They  were  twice 
as  wide  as  found  in  normal  muscles  but  even  those  of 
the  healthy  arm  were  one-quarter  wider.  The  muscular 
corpuscles  were  increased  corresponding  to  the*  en- 
largement. 

On  operation  the  increased  amount  of  blood,  not  only 
the  externally  visible  one  of  the  skin  but  also  that  of  the 
muscle,  was  striking.  The  operation  (performed  in  1871) 
was  foll&wed  by  severe  inflammation  and  suppuration  in 
the  affected  limb.  Auerbach  demonstrated  equal  strength 
of  both  arms  by  the  dynamometer ;  the  strength  of  the 
right  arm  had,  therefore,  not  increased  m  proportion 
to  the  muscular  hypertrophy. 

It  is  uncertain  whether  a  venous  thrombosis  preceded 
the  disease  in  Redlich's  (135)  case,  though  the  history 
of  the  case  speaks  for  it  to  such  an  extent  that  Red- 


NUTRITIVE   EFFECT   OF   HYPEREMIA  145 

lich  assumes  this  as  positive.  The  patient,  while  suffer- 
ing from  acute  fever,  suddenly  complained  of  violent 
pains  in  the  left  leg,  which  were  followed  by  a  consider- 
able swelling.  The  limb  remained  enlarged,  the  patient 
continuing  to  experience  abnormal  sensations  therein: 
The  attending  physician  had  diagnosed  "lymphangitis." 
Six  years  later  the  patient  was  examined  by  Redlich, 
who  found  a  considerable  swelling  of  the  left  leg,  espe- 
cially of  the  calf.  The  enlargement  was  principally 
caused  by  the  muscles  but  the  skin,  too,  participated  in 
it.  The  bones  were  normal.  The  growth  of  hair  was 
less  on  the  affected  side-.  The  skin  was  marbled  but — 
except  some  varices  on  the  left  half  of  the  scrotum — 
there  was  not  noticeable  any  decided  venous  dilatation. 
This  patient,  too,  complained  of  muscular  weakness, 
paresthesia  and  pains,  but  these  were  not  lacking  also 
in  the  right  leg.  The  patient  suffered  from  other  nervous 
phenomena,  such  as  pupillary  contraction,  disturbances  of 
speech,  etc.  Redlich  considered  these  as  incipient  pro- 
gressive paralysis. 

A  particle  of  muscle  was  excised  from  the  calf  of  the 
hypertrophic  leg  for  examination.  During  this  procedure 
was  found  a  thickened  skin  with  a  deep  layer  of  subcu- 
taneous fat.  After  division  of  the  fascia  there  appeared 
a  layer  of  fat,  below  which  was  the  muscle.  This  looked 
pale  but  otherwise  normal.  Hemorrhage  from  the  wound 
was  insignificant.  Redlich  found  generally  normal  mus- 
cular tissue  on  microscopic  examination.  The  interstitial 
tissue  was  dense  and,  like  the  vessels,  showed  cellular 
infiltration.  Much  blood  pigment  was  found  in  cor- 
puscles. 

It  is  possible  yet  highly  improbable,  that  the  case 
reported  by  Hitzig  (136)  belongs  to  our  group.  In  a 
young  man  an  injury  to  the  right  supraclavicular  fossa 
was  followed  by  venous  stasis  and  muscular  hypertro- 
phy. As  there  also  existed  paralysis  of  the  muscles  of 
the  chest  it  is  very  probable  that  this  case  was  one  of 
nervous  trouble.  Of  importance  is  the  fact,  demonstrated 
by  Hitzig,  that  the  affected  upper  and  fore  arm  was 
longer  than  the  heakhy  one,  a  thing  which  was  not 
noticed  in  any  of  the  preceding  cases. 

These  observations,  the  majority  of  which  are  unob» 
10 


146         NUTRITIVE  EFFECT  OF  HVPEREMIA 

jectionable,  leave  us  in  no  doubt  that  as  a  consequence 
of  a  pronounced  venous  stasis,  as  it  occurs  after  venous 
thrombosis,  an  enlargement  of  the  limbs  takes  place 
which  concerns  exclusively  or  essentially  the  muscles.  It 
would  also  seem  that  the  proof  has  been  established  by 
the  microscopic  findings  of  the  various  investigators  that 
we  here  have  to  deal  with  a  true  hypertrophy.  This 
proof,  however,  is  utterly  shaken  by  contributions  from 
Oppenheim  and  Siemerling  (137),  which  show  that  the 
fibers  of  pieces  of  muscle  taken  from  living  men  and 
animals  always  make  the  impression  as  if  they  were  hy- 
pertrophic.  This  is  so  conclusive  that  Oppenheim  and 
Siemerling  always  can  tell  with  the  microscope  whether 
muscles  have  been  taken  from  a  living  being  or  a  corpse. 
Zuntz  expressed  the  idea  that  living  muscle  strongly 
contracts  when  irritated  by  cutting  or  contusing  instru- 
ments and  reagents,  so  that  the  thickness  of  its  fibers 
increases  at  the  expense  of  length.  Oppenheim  and 
Siemerling  substantiated  the  correctness  of  this  expla- 
nation by  experiments  on  animals.  However,  with  the 
exception  of  an  enlargement  of  the  fibers,  the  above- 
mentioned  observers  have  found  no  other  positive  sign 
of  a  true  hypertrophy  of  muscles.  Eulenburg  found 
degenerated  muscle  fibers  and  states  expressly  that  there 
existed  a  fatty  infiltration  in  the  muscle,  which  appeared 
in  characteristic  series  as  found  in  pseudo-hypertrophy 
of  the  muscles.  Redlich  found  normal  muscular  tissue 
and,  on  the  other  hand,  increase  of  interstitial  tissue  char- 
acteristic of  pseudo-hypertrophy. 

It  must  be  added  that  in  all  cases  (except  in  Lesage's 
case,  in  which  the  diseased  muscle,  however,  tired  more 
rapidly)  the  weakness  of  the  enlarged  muscles  by  no 
means  can  be  accepted  as  a  sign  of  true  hypertrophy. 
Thus  Auerbach  and  Redlich  are  of  the  opinion  that 
this  so-called  "true  muscular  hypertrophy"  represents 
the  first  stage  of  the  lipomatous  pseudo-hypertrophy. 

The  conclusion  which  we  draw  from  these  widely 
discussed  diseased  conditions  is  this :  It  is  doubtless  that 
increase  in  volume  of  affected  limbs  and  especially  of 
the  muscles  may  follow  a  venous  thrombosis.  Whether 
this  is  a  true  hypertrophy  or'the  first  stage  of  a  degenera- 
tion of  the  muscular  tissue  proper  is  unknown. 


NUTRITIVE  EFFECT  OF  HYPEREMIA         147 

For  our  practical  purposes,  however,  we  can  draw  a 
positive  conclusion,  viz. :  Under  HO  condition  is  it  permis- 
sible to  artificially  produce  stases  of  such  intensity  as 
those  which  produce  the  so-called  muscular  hypertrophy. 
For  we  learn  that  in  the  majority  of  such  cases  the  stasis 
at  the  same  time  produces  nervous  derangements  and 
the  result  of  the  increase  of  the  muscles  was  a  decrease 
and  not  an  increase  of  their  usefulness. 

It  is  possible  that  a  true  hypertrophy  could  be  pro- 
duced with  a  less  intense  stasis  hyperemia  while  that 
intense  hyperemia  after  a  transient  hypertrophy  leads 
to  degeneration.  Against  this  is  the  fact  that  in  many 
hundreds  of  cases  which  I  have  treated  with  degrees  of 
stasis  hyperemia  permitted  for  therapeutic  purposes,  I 
have  never 'seen  a  muscular  hypertrophy.  However,  I 
have  seen  that  limbs  grown  lean  because  of  joint  diseases 
rapidly  regained  their  former  condition,  but  no  more 
so  than  could  be  explained  with  the  improvement  of  the 
causative  disease,  for  muscles  and  other  tissues  in  many 
affections  of  the  joints  not  only  atrophy  with  great 
rapidity  but  also  recuperate  just  as  rapidly  if  the  cause 
be  removed. 

Without  doubt  both  active  and  passive  hyperemia  lead 
to  rapid  growth  of  the  covering  epithelial  structures. ' 
Thus,  it  is  known  that  in  summer,  when  the  skin  is  sup- 
plied with  a  greater  quantity  of  blood  than  in  winter, 
hair  and  nails  grow  faster.  Besides  there  are  numerous 
observations  which  prove  that  the  same  occurs  in  all 
chronic  hyperemias.  In  addition  decided  exfoliation  of 
the  epidermis  has  been  observed.  To  this  class  possibly 
belongs  the  so-called  desquamative  catarrh  of  stasis  lung, 
in  which  the  alveoli  of  the  lung  are  filled  with  masses 
of  shed  epithelia. 

Every  physician  knows  that  in  the  vicinity  of  chronic 
ulcers,  accompanied  by  hyperemia,  frequently  increased 
growth  of  hair  and  epithelial  thickening  can  be  observed. 
Leber  (138)  could  even  artificially  produce  them  by 
injecting  phlogosin,  a  substance  producing  inflammation 
compounded  by  him. 

From  my  own  and  Helferich's  observations  can  be  seen 
that  increased  growth  of  hair  very  often  follows  passive 
hyperemia ;  we  frequently  saw  the  appearance  of  in- j 


148  NUTRITIVE   EFFECT   OF   HYPEREMIA 

creased  growth  of  hair  after  artificially  applied  stasis 
hyperemia. 

That  arterial  hyperemia  has  the  same  effect  can  be 
seen,  aside  from  the  above-mentioned  growth  of  hair  in 
summer,  by  the  hairy  hands  of  surgeons,  which,  as  a 
consequence  of  repeated  washings,  are  in  a  continuous 
condition  of  hyperemia.  It  has  been  assumed  that  one 
or  another  of  the  chemicals  employed  is  responsible  for 
this ;  however,  all  washing  agents  act  alike  in  this  respect 
and  therefore  the  hyperemia  remains  the  sole  cause. 

A  striking  example  for  the  increased  growth  of  an 
epithelial  structure  under  the  influence  of  hyperemia  is 
given  by  the  frequently  cited  experiment  of  J.  Hunter, 
reported  by  Paget  (139)  :  If  the  spur  of  a  rooster  be 
transplanted  into  the  hyperemic  tissue  of  its  comb,  the 
spur  will  develop  to  an  enormous  size. 

It  can  therefore  be  considered  as  established  that 
active  and  passive  hyperemia  produce  increased  growth 
of  cover  epithelium.  On  the  other  hand,  I  know  of  not 
a  single  case  which  could  prove  that  secreting  glandular 
epithelium  is  hypertrophied  by  hyperemia.  On  the  con- 
trary, we  will  soon  show  that  chronic  stasis  in  the  liver 
produces  even  atrophy  of  the  epithelial  cells. 

I  have  repeatedly  observed  that  testicles,  which  can 
scarcely  be  counted  among  the  secreting  glands,  greatly 
enlarged  under  the  influence  of  stasis  hyperemia,  which 
I  had  employed  against  tuberculosis  or  for  the  dissolu- 
tion of  hard  infiltrations  following  gonorrheal  infection. 
This  enlargement  remained  for  some  time  after  the  ces- 
sation of  the  hyperemia.  In  one  case  of  pronounced 
induration  of  the  epididymis  and  fistula  of  one  testicle 
following  gonorrhea,  I  rendered  hyperemic  both  testes  by 
means  of  a  rubber  tube  applied  at  the  base  of  the  scro- 
tum. The  patient  complained  that  at  first  he  was  tor- 
tured from  intense  pollutions,  which  occurred  several 
times  during  the  night,  while  previously  he  rarely  had 
a  pollution  during  the  night.  This  disappeared  after  a 
temporary  cessation  of  the  application  and  did  not  re- 
turn on  shorter- application  of. the  constrictor. 

As  I  never  have  been  in  the  position  to  anatomically 
examine  testes  enlarged  by  artificial  stasis  hyperemia  it 


NUTRITIVE    EFFECT   OF   HYPEREMIA  149 

must  remain  unanswered  as  to  what  causes  the  enlarge- 
ment and  which  tissues  are  involved. 

As  is  known,  it  has  been  held  that  chronic  blood-stasis 
in  the  viscera  due  to  heart  disease,  emphysema,  etc-.,  pro- 
duces an  increase  of  connective  tissue  in  them,  desig- 
nated as  cyanotic  induration. '  I  deem  it  useful  to  briefly 
review  the  changes  which  occur  in  the  viscera  in  this 
chronic  stasis,  according  to  Ziegler's  text-book  on  path- 
ological anatomy: 

The  chronic  engorged  spleen  is  normally  large  or  en- 
larged, larely  diminished.  It  is  always  indurated.  The 
hardness  is  caused  by  the  compactness  of  the  red  pulp. 
"The  main  change  consists  in  an  increase  of  connec- 
tive tissue  which  concerns  not  only  the  trabecular  sys- 
tem but  also  the  walls  of  the  blood-vessels  and  .their 
vicinity.  Occasionally  a  partial  induration  of  the  reticu- 
lum  of  the  pulp  cords  can  be  demonstrated." 

The  liver  in  chronic  stasis  is,  as  a  rule,  somewhat  dimin- 
ished, its  surface  sometimes  uneven  and  granulated.  On 
microscopic  examination  the  veins,  especially  the  venulre 
centrales  including  the  near-by  capillaries,  are  found  to 
be  dilated.  In  the  more  intense  forms  of  stasis  all  capil- 
laries of  the  lobules  are  dilated.  "The  liver  cells  between 
the  dilated  capillaries  are  always  more  or  less  atrophic 
and,  as  a  rule,  also  studded  with  .yellow  and  brown 
pigment  granules,  some  with  fat-drops.  Degeneration 
has  progressed  farthest  in  the  center  and  in  the  middle 
zones  of  the  acini.  If  the  circulatory  disturbances  and 
pronounced  dilatation  of  the  capillaries  has  lasted  for 
some  time,  a  part  of  the  liver  cells  may  have  perished 
so  that  there  remains  between  the  wide  capillaries  onlv 
pigment  granules.  The  periportal  connective  tissue  of 
the  liver  is,  as  a  rule,  unchanged,  yet  it  occurs  that  it 
becomes  hypertrophic  and  infiltrated  by  cells  so  that  a 
special  kind  of  cirrhosis  develops." 

The  chronically  engorged  kidney  is  hard  and  firm,  "the 
connective  tissue  between  the  urinary  canaliculi  is  some- 
what enlarged,  the  blood-vessels  are  wide  and  gaping, 
the  walls  of  the  capillaries  and  the  adventitia  of  the  veins 
thickened.  Occasionally  there  occur  inflammatory  cellu- 
lar infiltrations."  Many  of  the  epithelia  of  the  canaliculse 
become  fatty. 


150         NUTRITIVE  EFFECT  OF  HYPEREMIA 

In  chronic  stasis  of  the  lung,  the  vessels  of  this  organ, 
especially  the  capillaries,  are  much  dilated,  protruding 
into  the  alveoli.  The  lung  becomes  hard.  "In  some 
spaces  the  connective  tissue  is  dense  or  in  the  process 
of  inflammation  or  granulation,  but  this  is  due  less  to 
the  stasis  than  to  repeated  hemorrhages  found  in  such 
lungs." 

As  I  found  in  the  literature  variable  statements  con- 
cerning the  degree  of  granulation  of  connective  tissue  in 
engorged  viscera,  I  asked  my  colleague,  Professor  Gra- 
witz,  to  give  me  his  experience  on  this  point.  This 
pathologist  granted  my  request  with  great  cordiality  and 
supported  his  statements  with  .instructive  microscopic 
specimens,  so  that  I  became  convinced  as  to  the  correct- 
ness of  his  descriptions. 

According  to  Grawitz,  thickening  and  granulation  of 
connective  tissue  is  most  intense  in  the  engorged  spleen. 
However,  he  is  in  doubt  whether  this  change  is  solely  due 
to  the  chronic  stasis  or  whether  other  causes,  too,  co- 
operate. 

The  engorged  lung  owes  its  density  rather  to  the  ful- 
ness of  the  capillaries  (incision  and  pressure  soften  the 
lung),  partially  also  to  atelectases  and  filling  of  the 
alveoli  with  a  primary  exsudate  and  detached  cells,  than 
to  granulation  of  the  connective  tissue.  Even  in  the 
most  intense  forms  of  chronic  stases  the  increase  in  con- 
nective tissue  may  be  absent  yet  the  "brown  indura- 
tion" of  the  lung  is  present. 

If  the  stasis  has  persisted  for  some  time  in  the  liver, 
the  capillaries  of  the  lobules  are  greatly  dilated,  especially 
around  the  central  vein.  At  the  same  time,  destruction 
of  liver  cells  takes  place.  This  can  be  plainly  recognized 
in  fresh  specimens,  when  affected  by  water,  by  the 
fact  that  the  row  of  liver  cells  commences  at  a  dis- 
tance from  the  central  vein.  In  the  stased  space  one  can 
observe  only  remnants  of  broken-down  liver  cells  with- 
out infiltration  of  small  cells.  In  grave,  prolonged  stasis 
destruction  of  the  liver  cells  extends  over  the  entire 
lobule  and  frequently  reaches  an  enormous  circumference. 
The  final  result  of  severe,  chronic  stasis  of  the  liver, 
according  to  Grawitz,  is  atrophy  of  the  liver  cells  and, 
as  a  rule,  without  development  of  connective  tissue. 


NUTRITIVE  EFFECT  OF  HYPEREMIA         151 


The  congested  kidney  is  dense  to  the  feel  but  can  be 
differentiated  from  chronic  interstitial  nephritis  by  the 
surface,  which  is  smooth  without  formation  of  scars. 
Thickening  of  connective  tissue  may  be  present  or 
absent,  even  in  the  most  developed  forms  of  chronic 
stases.  If  it  is  present,  it  is  even  and  neither  forms 
single  foci  nor  produces  infiltration  of  small  cells ;  it 
is  always  without  influence  on  the  epithelial  parts  of 
the  kidney. 

Grawitz  admits  that  chronic  stasis  of  the  viscera  fre- 
quently produces  increase  of  connective  tissue  but  insists 
that  this  by  no  means  happens  regularly  and  that  in 
many  cases  of  pronounced  chronic  stasis  it  is  entirely 
lacking. 

It  is  known  that  lively  connective  tissue  granulation 
follows  after  chronic  inflammations ;  we  know  this  espe-, 
cially  from  the  chronic  ulcer  of  the  leg,  where  inflam- 
mation and  intense  blood-stasis  go  hand  in  hand. 

We  further  know  that  chronic  blood-stasis  and  more 
frequently  lymph-stasis  and  repeated  attacks  of  chronic 
inflammation  may  lead  to  thickening  of  the  skin — the  so- 
called  elephantiasis. 

No  doubt  exists  in  regard  to  the  influence  of  passive 
hyperemia  on  the  growth  of  the  bones,  both  in  length  and 
thickness.  Stanley  (140)  and  Paget  (141)  made  the 
first  observations  in  this  direction,  and  v.  Bergman  (142) 
collected  the  then  known  material  in  an  article  and  added 
two  new  cases.  These  reports  show  that  long  bones 
become  longer  and  thicker  if  inflammatory  processes  have 
taken  place  within.  Similar  observations  increased  rapid- 
ly and  Helferich  (143)  demonstrated  by  a  large  number 
of  cases  that  lengthening  of  bone  frequently  follows 
necrosis  (as  a  rule,  this  is  the  cause  of  inflammation), 
occurring  quickly  after  the  disease  has  taken  hold.  To- 
day this  fact  is  well  known  to  every  physician  and  there 
is  scarcely  a  surgeon  who  has  not  seen  such  cases  in  a 
large  number.  It  is  therefore  unnecessary  to  enter  into 
details. 

Even  the  earliest  observers  attributed  this  hypertrophy 
to  the  hyperemia  produced  by  the  inflammation,  v.  Lang- 
enbeck  (144)  framed  his  observations  in  the  following 
three  sentences : 


•30  \ 

152         NUTRITIVE  EFFECT  OF  HYPEREMIA 

M1ASO 

I.  Diseases  which  ca^if^e  irritation  and  hyperemia  of 
bone  tissue  produce  an  increase  in  the  length  and  thick- 
ness of  the  bone  while  the  growth  of  bone  lasts. 

2..  The  increase  in  the  length  concerns  first  of  all  the 
affected  bone,  but  can  also  be  observed  in  a  healthy 
bone  of  the  same  extremity. 

3.  The  bone  lengthened  by  this  too  rapid  growth  re- 
tains its  dimensions  throughout  life.  A  decrease  in 
length  by  resorption  does  not  take  place  even  though  its 
cause,  .the  disease  of  the  bone,  has  ceased  to  exist  for 
a  long  time. 

Oilier  (145)  found  that  the  length  of  the  long  bones 
in  young  growing  animals  could  be  increased  by  all  sorts 
of  irritation  of  the  diaphysis,  by  tearing,  excision  and 
cauterization  of  the  periosteum,  by  trephining  of  the 
medullary  canal  or  by  the  introduction  of  foreign  bodies, 
provided  the  irritation  was  maintained  long  enough. 

In  1868  Schneider  (146)  reported  a  case,  a  young  man 
seventeen  years  old,  whose  tibia  and  fibula  became  in- 
creased in  length  in  connection  with  a  chronic  ulcer  of 
the  leg,  and  since  then  this  phenomenon  has  been  re- 
peatedly observed  in  young  individuals.  That  these 
ulcers  led  to  thickening  of  bone  and  even  to  ossification 
of  the  ligamentum  interosseum  had  been  known  for  a 
long  time.  Schneider  attributed  this  hypertrophy  to  an 
increase  of  blood  produced  by  chronic  inflammation 
in  a  young  person. 

These  observations  made  it  very  probable  that  the 
venous  hyperemia  which  accompanies  all  inflammations 
is  the  cause  of  the  growth  in  length  and  width  of  the 
bones.  A  number  of  cases  now  prove  this  to  be  a  posi- 
tive fact,  since  a  pure  venous  hyperemia  was  followed  by 
the  same  result. 

The  following  observation  by  Broca  (147),  so  often 
cited  in  literature,  belongs  to  this  number:  A  man, 
seventeen  years  old,  suffered  for  two  years  from  a  con- 
stant venous  hyperemia  of  a  leg,  produced  by  an  arterio- 
venous  aneurysm  below  Poupart's  ligament.  The  thigh 
was  increased  by  2,  cm. ;  the  leg  by  I  cm.  by  the  hy- 
peremia. 

Krause  (148)  describes  a  case  of  numerous*  sac-like 
aneurysms  of  the  forearm  and  hand  and  pronounced  vari- 


NUTRITIVE   EFFECT  OF   HYPEREMIA  153 

cose  dilatation  of  the  veins  of  the  dorsum  of  the  hand 
and  forearm,  due  to  a  bite  from  a  dog  in  youth.  These 
maintained  for  many  years  venous  hyperemia  of  the 
extremities  and  led  to  ulcers  of  the  fingers.  Stromeyer 
amputated  the  extremity  at  the  upper  arm.  Krause 
established  that  the  forearm  was  longer  by  il/2  Parisian 
inches. 

A  similar  case  is  described  by  Nicoladoni  (149).  In 
this  case  too  a  cirsoid  aneurysm  and  decided  formation 
of  varices  led  to  a  prolonged  Venous  hyperemia  of  the 
arm,  which  produced  an  increase  in  the  length  of  the 
forearm.  Israel  (150)  describes  a  leg  lengthened  5  cm. 
by  venous  hyperemia  due  to  a  congenital  angiectasis 
and  Hitzig  (151)  describes  an  arm  whose  fore  and 
upper  arm  each  were  several  centimeters  longer,  due 
to  a  venous  stasis  of  unknown  origin. 

Probably  the  so-called  drumstick  fingers,  consisting  of 
an  enlargement  of  the  bone,  nail  and  end  phalanx  of  the 
fingers,  sometimes  also  of  the  toes,  belong  to  this  class. 
These  are  observed  in  grave  affections  of  the  heart,  origi- 
nating in  childhood,  emphysema,  bronchiectasis  and 
phthisis  pulmonalis  and  in  diseases  producing  chronic 
stasis.  Bamberger  described  in  these  affections  thicken- 
ing of  the  bones  of  the  legs  and  forearms.  Fischer  (152) 
believes  that  he  is  able  to  prove  their  development  from 
hyperemia  by  the  fact  that  in  such  cases  he  found  an 
increase  of  i°  C.  in  the  surface  temperature  of  the  palms 
as  compared  with  other  parts.  It  seems  to'me  that  this 
is  no  proof,  for  even  normally  the  surface  temperature 
is  somewhat  higher  in  the  palm  than  elsewhere  on  the 
arm.  However,  it  is  probable  that  they  owe  their  de- 
velopment to  chronic  stasis  and  not  to  the  resorption 
of  gangrenous  substances  from  bronchiectases  and  cav- 
ernous spaces,  as  is  held  by  Bamberger.  Against  the  latter 
view  speaks  their  occurrence  with  heart  diseases  and  a 
case,  described  by  Fischer,  of  a  cachectic  child  suffering 
from  craniotabes  which  was  frequently  attacked  by 
asphyxia,  which  again  led  to  stases  and  drumstick  fingers. 

There  is,  therefore,  no  doubt  that  a  prolonged  venous 
hyperemia  produces  hypertrophy  of  bones  and  of  epithe- 
lial structures,  principally  hair.  However,  as  the  above- 
described  cases  of  muscular  hypertrophy  are,  to  say  the 


154         NUTRITIVE  EFFECT  OF  HYPEREMIA 

least,  uncertain,  I  know  of  not  a  single  case  of  a  bodily 
part  or  organ  with  active  functions  which  has  been 
rendered  hypertrophic  by  venous  hyperemia,  the  observa- 
tions which  have  been  made  in  stased  viscera  speak  rather 
for  the  contrary. 

After  it  has  been  recognized  that  under  certain  circum- 
stances, superfluity  of  blood  produces  hypertrophy,  this 
fact  was  made  use  of  for  practical  purposes,  with  a  view 
to  stimulating  the  growth  of  parts  of  the  body  undevel- 
oped in  length  and  thickness  by  rendering  them  artifi- 
cially hyperemic.  Basing  on  a  successful  experiment 
on  an  animal,  v.  Langenbeck  recommends  in  the  above- 
cited  contribution  (in  1869)  to  hammer  ivory  pegs  into 
the  bones  of  shortened  extremities  of  men  (for  instance, 
after  resection  of  the  knee-joint)  and  thus  to  produce 
an  artificial  inflammatory  irritation,  a  proposition  which 
later  has  been  executed  repeatedly  in  practice. 

Oilier  (153)  recommended  irritations  of  the  periosteum 
in  the  middle  of  the  diaphysis  by  repeated  cauterization 
and  other  caustic  agents  in  order  to  increase  the  length 
of  bones.  He  succeeded  in  lengthening  the  shortened 
shin-bone  of  a  young  girl  i  cm.  by  the  application  of 
caustic  paste. 

Helferich  (154)  made  the  pure'  experiment  of  furthering 
the  physiological  growth  of  bone  by  means  of  artificial 
stasis  hyperemia.  He  reported  the  following  cases  in 
which  he  observed  the  development  of  hypertrophy  of 
diverse  tissues  by  hyperemia : 

1.  A  boy  has  been  treated  for  years  for  congenital  luxa- 
tion with  an  apparatus  which  produced  stasis  hyperemia 
in  the  diseased  leg.    As  a  consequence,  skin  and  muscles 
became  thicker,  while  the  bones  increased  in  length. 

2.  A  sixteen-year-old  girl  experienced  an  increase  of 
3  cm.  in  her  leg  from  a  chronic  ulcer.     Helferich  suc- 
ceeded in  lengthening  the  healthy  extremity  2  cm.  by 
stasis  hyperemia.     This  artificial  hyperemia  produced  a 
true  thickening  of  the  skin. 

3.  Boy,  ten  years  old,  leg  shortened  3^   cm.  subse- 
quent to  a  fracture  of  the  femur  and  lengthened  il/2  cm. 
by  stasis  hyperemia. 

4.  Girl,  aged  nine  years,  who  had  a  slight  paralysis  of 
a  leg.     After,  the   application  of  stasis   hyperemia   for 


NUTRITIVE  EFFECT  OF  HYPEREMIA         155 

four  months  there  was  a  slight  lengthening  of  the  tibia, 
thickening  of  the  skin  and  increased  growth  of  hair. 

Helfench  states  that  he  has  used  artificial  hyperemia 
also  in  five  cases  of  infantile  paralysis  but  he  was  not 
able  to  control  the  effect  because  of  the  shortness  of  the 
treatments. 

Helferich's  remark  that  after  a  prolonged  application 
of  stasis  hyperemia  he  regularly  observed  thickening 
of  the  skin  without  edema,  i.  e.,  true  hypertrophy  of  the 
skin,  is  indeed  noteworthy. 

His  observations  concerning  the  favorable  influence 
of  stasis  hyperemia  on  the  formation  of  callus  will  be 
discussed  elsewhere ;  we  will  here  discuss  his  attempts 
to  improve  the  deficient  formation  of  sequestra  by  means 
of  stasis  hyperemia.  He  succeeded  in  improving  the 
formation  of  sequestra  in  cases  of  spontaneous  fracture 
from  total  necrosis.  Helferich  successfully  used  a  mild 
stasis  hyperemia  for  the  rapid  production  of  an  involu- 
crum  before  solution  of  the  sequestrum. 

Schiiller  (155)  repeated  Helferich's  experiments  to 
treat  atrophy  and  shortening  of  bone  with  artificial  stasis 
hyperemia,  he,  however,  added  massage,  inunctions  and 
sea-baths,  so  that  the  results  of  his  treatment  are  not 
pure.  In  addition,  he  instituted  a  dietetic  treatment  con- 
sisting of  good  nourishment  and  the  introduction  of  cal- 
cium salts  and  limitation  of  the  consumption  of  lactic 
acid  from  the  food.  He  experienced  good  results  in 
several  cases  of  infantile  spinal  paralysis  which  had 
resulted  in  shortening  and  muscular  atrophy.  After  sev- 
eral months  of  treatment  he  succeeded  in  not  only  even- 
ing the  shortening  of  the  bones  but  also  in  considerably 
improving  the  muscular  atrophy. 

In  three  cases  Schiiller,  previous  to  the  institution  of 
this  treatment,  drove  nickeled  steel  tacks  in  the  bones. 
There  were  left  in  situ  five  to  nine  days  and  then  removed. 
After  two  weeks  stasis  hyperemia,  etc.,  was  instituted. 

The  first  of  these  cases  has  improved  so  strikingly  that 
it  merits  brief  quotation:  A  sixteen-year-old  girl,  who 
had  been  attacked  by  infantile  spinal  paralysis  when  two 
and  one-half  years  old,  still  had  as  a  sequela  a  shortening 
of  3  cm.  of  the  right  leg,  a  diminution  of  the  right  foot, 
decided  atrophy  of  the  calf,  complete  paralysis  of  the  toes, 


156  NUTRITIVE   EFFECT  OF  HYPEREMIA 

lividity  and  coldness  of  the  skin  of  the  foot.  The  de- 
scribed treatment,  which  was  maintained  for  eight 
months,  has  produced  a  lengthening  of  the  leg  so  as  to  be 
almost  even  with  the  healthy  one,  enlargement  of  the 
foot  and  "the  calf,  which  before  had  almost  entirely  dis- 
appeared, has  become  full  again."  The  toes  now  can 
be  moved  actively,  that  is  to  say,  flexed  and  extended, 
while  before  they  were  never  moved  spontaneously.  The 
foot,  which  was  always  blue  and  ice-cold  and  could 
make  no  other  motion  save  that  of  limited  dorsal  flexion 
and  which,  when  left  alone,  regularly  tinped  outwardly, 
now  has  normal  color  and  warmth  and  can  be  moved 
actively  in  every  direction. 

It  must  be  added  that  Schuller  previously  had  per- 
formed arthrodosis  of  the  foot  and  section  ot  the  plantar 
aponeurcsis,  and  in  addition  to  the  hyperemic,  gymnastic 
and  dietetic  methods  has  treated  the  case  also  orthopedi- 
cally. 

Of  great  importance  also  is  Schiiller's  assertion  that  he 
has  produced  one-sided  formation  of  bone  tissue.  In  a 
case  of  pronounced  genua  valga  due  to  rachitis,  he  drove 
nickeled  steel  nails  on  the  outside  of  both  femora  about 
two  fingers  breadth  above  the  epiphyseal  line  and  re- 
moved them  after  five  days.  Two  weeks  later  the 
described  method — stasis  hyperemia,  massage  and  gym- 
nastic— was  instituted  and  the  child  sent  to  a  sea  resort. 
Four  and  one-half  months  later  the  worse  deformity  had 
entirely  disappeared,  the  other  considerably  improved. 
Schuller  attributes  this  difference  to  the  right  nail,  which 
was  driven  in  deeper  than  the  left  one.  Both  legs  had 
greatly  increased  in  length,  which  Schuller  attributes  to 
his  treatment,  therefore,  to  the  lengthening  of  the  thighs. 
Since  we  know  that  rachitic  genua  valga  frequently  dis- 
appear after  the  institution  of  a  rational  hygienic  therapy 
only,  which  was  also  done  here,  this  case  loses  much  of 
its  value  as  proof. 

While  the  observations  concerning  the  influence  of 
passive  hyperemia  on  hypertrophy  are  numerous,  they 
are  limited  in  regard  to  active  hyperemia.  I  have  already 
mentioned  that  the  latter  produces  an  increase  in  the 
growth  of  hair. 

Bidder  (156)  removed  from  a  young  rabbit  a  piece  from 


NUTRITIVE  EFFECT  OF  HVPEREMIA         157 

one  sympathicus  1.5  cm.  long  and  thus  produced  arterial 
hyperemia  of  the  concerned  ha4f  of  the  head.  The  ear  on 
that  side  became  wider  and  longer  than  that  on  the 
healthy  side.  The  same  experiment  with  like  success  was 
performed  by  Stirling-  (157)  on  young,  growing  rabbits 
and  dotq-s. 

Penzo  (158)  made  one  of  the  ears  of  a  growing  rabbit 
lastingly  hyperemic  by  subjecting  it  throughout  the 
greatest  part  of  the  day  to  a  temperature  of  +  37  to 
38°  C.,  the  other  at  the  same  time  anemic  by  employing 
a  temperature  of  +  10  to  12°  C.  In  five  experiments 
he  always  obtained  the  same  result:  the  hyperemic  ear 
grew  much  faster.  According  to  a  photograph  of  the 
head  of  a  rabbit  thus  treated  the  difference  in  size  was 
considerable. 

Here  belongs  also  the  above-cited  experiment  by  I. 
Hunter,  the  unusual  growth  of  a  spur  of  a  rooster  trans- 
planted into  the  hyperemic  comb. 

In  opposition  to  this,  Virchow  (159)  says  that  one  can 
(probably  in  grown  animals)  maintain  hyperemia  of  half 
the  head  for  weeks  and  months  by  cutting  the  sympath- 
icus without  producing  the  least  change  in  nutrition 
and  Cohnheim  (160)  says  the  same  even  of  young, 
growing  animals. 

Even  atrophy  has  been  observed  after  arterial  hyper- 
emia due  to  resection  of  nerves.  Thus  Schiff  has  seen 
atrophy  of  the  laryngeal  lobe  in  the  turkey ;  Legros  re- 
moved the  uppermost  ganglion  of  the  sympathicus  of  a 
young  rooster,  which  was  followed  by  atrophy  of  the 
comb  on  the  concerned  side,  and  Brown  Sequard  and 
Yulpian  (161),  after  cutting  through  the  sympathicus  of 
a  guinea  pig,  observed  atrophy  of  the  brain  on  the  related 
side. 

These  experiments  therefore  prove  that  artificial  arte- 
rial hyperemia  produced  by  sectron  of  vasomotoric  nerves, 
though  frequently  producing  hypertrophy,  is  not  neces- 
sarily always  followed  by  this  result.  I  have  already 
remarked  that  the  following  every-day  experiences  speak 
against  the  arterial  hyperemia  under  natural  conditions 
producing  hypertrophic  effects :  People  who  expose  dur- 
ing the  largest  part  of  the  day  their  skin,  especially  that 
of  the  face,  against  high  temperatures,  thus  rendering 


158  NUTRITIVE    EFFECT   OF   HYPEREMIA 

it  hyperemic,  such  as  glass-blowers,  foundrymcn,  stokers, 
.bakers,  by  no  means  have  a  hypertrophic  skin  but,  on 
the  contrary,  one  characterized  by  delicacy  and  paleness 
when  away  from  heat. 

.  My  own  hands  and  forearms,  since  I  have  become  a 
surgeon,  on  account  of  the  repeated  washings,  are  in  a 
continuous  state  of  hyperemia,  which,  to  judge  from 
the  color,  is  an  arterial  hyperemia  ;  the  skin  of  these  parts, 
however,  has  by  no  means  become  hypertrophic,  if  any- 
thing, rather  atrophic. 

Among  hundreds  of  cases  which  I  have  treated  with 
active  hyperemia  by  means  of  hot  air,  I  have  not  seen  a 
single  case  in  which  this  agent  has  produced  an  increase 
in  the  nutrition  of  the  treated  part  which  could  not  be 
explained  by  the  improvement  of  the  affection  proper. 

With  the  exception  of  the  observations  by  Helferich 
and  Schuller,  I  have  found  nowhere  in  the  literature  data 
on  experiments  to  accelerate  physiologic  growth  and  to 
remove  existing  atrophies  by  pure  stasis  hyperemia.  I 
am  not  aware  that  it  has  been  tried  to  achieve  the  same 
purpose  by  active  hyperemia.  This  is  due  to  the  fact  that 
whatever  observations  on  hypertrophy  subsequent  to 
hyperemia  were  accidentally  made  concerned  almost  ex- 
clusively the  venous  hyperemia.  To  this  must  be  added 
that  previous  to  my  recommendation  to  utilize  high  de- 
grees of  heat  as  a  harmless  remedy  to  produce  active 
hyperemia  this  was  unknown.  It  is  impossible  to  pro- 
duce paralysis  of  vasomotoric  nerves  in  man.  For  this 
reason  I  deem  it  important  to  here  publish  a  few  obser- 
vations which  I  made  when  I  first  began  to  experi- 
ment with  hyperemia. 

I  tried  to  improve  the  pronounced  muscular  atrophy 
and  the  paralysis  by  artificial  hyperemia  in  three  cases 
of  spinal  infantile  paralysis  of  the  lower  extremities. 
There  were  no  shortenings  of  the  bones;  whether  the 
treatment  produced  an  increase  in  their  length  I  can  not 
tell,  as  I  have  made  no  examinations  in  this  respect.  I 
therefore  must  limit  my  description  to  the  effect  exer- 
cised by  the  hyperemia  on  muscles  and  skin. 

For  the  first  two  months  I  applied  in  the  three  cases 
prolonged  stasis  hyperemia.  The  constricting  bandage 
was  changed  to  a  different  place  twice  daily.  I  can 


NUTRITIVE  EFFECT  OF  HYPEREMIA         159 

confirm  Helferich's  observations  that  the  paralyzed  ex- 
tremities tolerated  this  method  of  treatment  very  well. 
I  could  not  observe  any  result  in  a  single  case. 
I  then  applied  two  to  three  hours  daily  artificial  arterial 
hyperemia  by  means  of  hot  air,  in  one  case  two  months, 
in  the  others  one  month  each.  This  also  was  well  toler- 
ated*. To  be  sure,  I  was  very  careful  and  never  per- 
mitted the  heat  to  become  excessive.  Hyperemia  never- 
theless appeared  in  a  sufficiently  intense  form.  In  one 
case  I  had  a  satisfactory  success  in  so  far  that  the  pre- 
viously cold  and  blue  limb  during  the  treatment  became 
warmer,  while  the  blue  color  faded.  However,  this  suc- 
cess disappeared  after  the  cessation  of  treatment.  The 
arterial  hyperemia  did  not  have  the  least  influence  on  the 
nutrition  of  the  skin  and  muscles.  In  one  case  it  even 
seemed  to  me  as  if  the  atrophic  skin  became  thinner  and 
more  sensitive. 

If  we  review  the  numerous  cases  and  observations 
which  have  been  cited  to  show  that  hyperemia,  as  such, 
produces  hypertrophy,  we  are  certain  only  that  as  a  con- 
sequence of  chronic  hyperemia  bones  frequently  experi- 
ence an  increase  in  length  and  thickness,  cover  epithelium 
granulates  and  connective  tissue  may  increase,  though 
this  is  not  always  the  case. 

As  far  as  the  muscles  are  concerned,  it  is  extremely 
doubtful  whether  they  become  hypertrophic  when  in- 
fluenced by  chronic  hyperemia.  Even  if  we  accept  that 
the  above-mentioned  cases,  anatomically  considered,  are 
true  hypertrophies,  physiologically  they  must  be  con- 
sidered degenerations,  as  they  led  to  muscular  weakness. 
Thus,  artificial  hyperemia  as  a  means  to  produce  mus- 
cular hypertrophy  in  practice  is  out  of  the  question,  espe- 
cially since  it  has  been  observed  in  such  intense  forms 
of  prolonged  stases  as  could  scarcely  be  made  use  of 
without  inflicting  injury  on  the  patient.  In  regard  to 
other  tissues,  we  know  of  no  unobjectionable  example 
which  shows  that  it  could  passively  be  placed  in  a  con- 
dition of  hypertrophy  by  hyperemia ;  on  the  contrary,  a 

*I  have  demonstrated  on  a  previous  occasion  (Virchow's  Archiv, 
Vol.  153,  p.  332)  that  the  vessels  of  cold,  blue,  paralyzed  limbs 
very  well  react  to  agents  which  produce  active  hyperemia,  as  the 
artificial  bloodlessness  normaliter  produces  in  them  a  pronounced 
reactive  hyperemia. 


160  NUTRITIVE   EFFECT  OF  HYPEREMIA 

few  observations  speak  for  it  that  intense  lasting  hyper- 
emia  may  even  produce  atrophy.  For  them,  therefore, 
holds  good  Vircliow's  dictum  that  the  cell  can  not  be 
nourished  passively  but  nourishes  itself,  thus  refusing 
the  nutrition  offered  in  excess,  unless  they  are  influenced 
at  the  same  time  by  stimuli,  the  nature  of  which  is  as  yet 
unknown  to  us,  which  cause  them  to  grow  and  multiply. 

On  the  other  hand,  we-  must  admit  that  as  far  as  the 
cover  epithelia  and  supporting  tissue  (bone,  cartilage, 
connective  tissue)  are  concerned  there  exists  a  possi- 
bility of  passive  nutrition  by  hyperemia,  though  occasion- 
ally this  may  not  occur,  as  is  shown  by  the  above-men- 
tioned observations. 

I  therefore  believe  that  Roux  (162)  is  correct  in  assum- 
ing that  only  the  organs  with  passive*  functions  (sup- 
porting tissue  and  cover  epithelium)  but  never  such  with 
active  functions  (muscles,  nerves,  secreting  epithelia) 
are  capable  of  increase  by  the  mere  increase  of  nutrition 
without  other  stimuli.  Before  I  knew  Roux'  statement, 
I  have  differentiated  these  things  in  such  a  way  that 
I  said:  Only  the  most  modest  tissues,  which  remain  alive 
and  exist  even  with  the  poorest  nutrition,  as  is  the  case 
with  the  supporting  substances  and  cover  epithelium, 
can  be  passively  nourished  by  hyperemia  but  not  the 
higher  organized  tissues. 

That  this  differentiation  between  the  diverse  tissues  is 
justified  is  shown  by  the  numerous  observations  of  the 
substitution  of  highly  developed  tissue  by  connective  tis- 
sue which  occurs  in  the  disturbances  of  nutrition.  This 
is  especially  plain  in  the  experiences  made  by  numerous 
experimenters  (163)  in  artificial  circulatory  disturbances 
in  the  kidney.  If  one  ligates  the  renal  artery,  either  alone 
or  with  the  renal  vein,  the  first  consequence  of  this 
operation  is  an  enormous  accumulation  of  venous  blood 
so  that  the  kidney  enlarges  two  to  three  times.  The  ac- 
cumulation occurs  because  the  empty  vascular  apparatus 

*Organs  functionating  purely  passively  do  not  exist.  Con- 
nective tissue  contains  the  lymph-nodules  and  therefore  partici- 
pates in  the  preparation  of  blood  and  perhaps  has  some  other 
•glandular"  functions.  Bone,  whose  function  to  sustain  weight 
and  muscle  tension  apparently  is  purely  a  passive  one,  contains 
tne  marrow  which  is  nlso  active  in  the  preparation  of  blood.  In 
spite  of  this  the  word  "passive"  here  will  scarcely  be  the  cause 
of  misunderstandings. 


NUTRITIVE  EFFECT  OF  HYPEREMIA         161 

of  the  kidney,  whose  artery  represents  an  "end  artery"  in 
Cohnheim's  sense,  is  first  of  all  filled  with  venous  blood 
.from  the  capillary  anastomoses  of  the  capsule.  Later 
the  hyperemia  decreases  and  the  kidney  is  even  found  to 
be  anemic.  After  about  eight  days  it  regains  its  former 
size,  then  shrinks  more  and  more  and  finally,  if  the  supply 
of  blood  has  been  effectively  interrupted,  becomes  a  small 
mass  of  connective  tissue,  in  which  «not  infrequently 
occurs  calcification.  The  microscopic  examination  of 
such  kidneys  shows  that  during  the  condition  of  venous 
blood  stoppage  the  epithelium  rapidly  dies  off.  Even 
when  the  ligation  lasts  but  a  few  hours  it  can  not  be 
saved.  In  its  place  there  appears  an  extraordinarily  rapid 
formation  of  connective  tissue,  which  at  first  is  rich  in 
blood  granulating  into .  the  kidney  from  various  sides 
but  finally  it  changes  into  a  shrinking  scar. 

These  experiences  show  us  how  careful  we  must  be  if 
we  generalize  observations,  which  show  hypertrophy  of 
individual  tissues  by  hyperemia  on  all  tissues. 

Thus,  I  must  stick  to  my  already  expressed  view  that 
I  consider  the  attempts  to  make  hypertrophic  by  arti- 
ficial hyperemia  formed  and  finished  bodily  parts  as  use- 
less. I  also  hardly  believe  that  one  could  succeed  in 
so  regularly  influencing  physiologic  growth  with  this 
agent  that  one  can  speak  of  a  method  with  which  the  de- 
sired purpose  can  be  obtained  with  some  certainty.  How- 
ever, I  do  not  doubt  that  under  certain  circumstances 
artificial  lengthening  of  growing  bones  can  be  produced 
by  that  agent.  I  must  hold  fast  to  this  negative  view  in 
spite  of  the  favorable  observations  made  by  Helferich 
and  Schuller.  Helferich's  cases  were  few.  He  could  in- 
crease the  length  of  shortened  growing  bones  in  the  four 
cases  in  which  he  used  stasis  hyperemia ;  in  the  five  cases 
of  paralyzed  extremities  treated  in  the  same  manner  he 
did  not  produce  muscular  hypertrophy.  As  far  as  the 
thickening  of  the  skin  is  concerned,  which  Helferich  has 
regularly  observed  after  application  of  stasis  hyperemia, 
I  am  inclined  to  accept,  for  reasons  to  be  stated  below, 
that  we  had  here  to  deal  essentially  with  a  chronic  edema. 

Schtiller's  results  in  producing  not  only  lengthening  of 
bones  but  also  considerable  hypertrophy  of  paralyzed 
muscles  are  indeed  very  striking.  But,  on  one  hand,  his 
11 


162  NUTRITIVE   EFFECT  OF  HYPEREMIA 

experiments  are  not  pure,  for,  in  addition  to  hyperemia. 
he  made  use  of  several  other  therapeutic  agents ;  on  the 
other  hand,  the  case  where  muscles  which  were  com- 
pletely paralyzed  thirteen  and  one-half  years  became 
thicker  and  regained  their  function  is  in  so  striking  a 
contrast  to  all  our  experience  concerning  the  restoration 
of  paralyzed  muscles  that  it  alone  can  scarcely  be  re- 
garded as  offering  any  proof. 

That  those  observations  are  limited  to  but  a  few  cases 
is  for  me  decisive.  I  can  only  repeat  that  among  the  many 
hundreds  of  cases  which  I  have  treated  with  stasis  hyper- 
emia and  among  the  many  hundreds  to  which  I  applied 
active  hyperemia,  with  the  exception  of  increased  growth 
of  hair  and  isolated  limited  lengthening  of  bone,  I  have 
never  seen  a  case  of  hypertrophy  of  tissues  due  to  the 
hyperemia  and  which  could  not  be  explained  in  the  sim- 
pler way  as  due  to  the  improvement  of  the  malady  itself. 
I  must  admit  that  we  have  not  sufficiently  paid  attention 
to  the  increase  of  growth  of  bones  in  length  and  that 
this  perhaps  occurred  oftener  than  we  have  assumed.  If, 
however,  this  had  occurred  regularly  and  to  a  great 
degree  it  could  not  have  escaped  us.  And  yet  I  have 
applied  treatment  with  hyperemia  in  several  cases  for 
years. 

After  having  written  this  for  some  time  I  made  the 
following  observation,  which  at  first  glance  seems  suited 
to  shatter  this  my  opinion : 

A  boy,  aged  eleven,  whose  father  died  of  phthisis,  became 
affected  in  March,  1902,  with  a  caries  sicca  tuberculosa  of  the  right 
shoulder-joint  and  entered,  May  13,  1902,  the  surgical  clinic. 

He  was  a  small,  lean  boy,  with  weak  muscles.  The  entire  region 
of  the  right  shoulder  was  very  lean.  This  concerned  especially  the 
deltoid  muscle  and  those  of  the  fossa  supra-and  infra-spinata,  so 
that  the  acromion  and  the  spine  of  the  scapula  protruded  promi- 
nently. The  joint  was  ankylosed,  the  scapula  participating  in  each 
attempt  at  motion  of  the  joint.  The  sulcus  intertubercularis  was 
sensitive  on  pressure,  the  right  arm  was  2l/2  cm.  shorter  than  the 
left  one.  The  Roentgen  picture  showed  considerable  destruction 
of  the  head  of  the  humerus. 

Stasis  of  the  shoulder,  as  depicted  in  Figure  7,  was  applied 
from  May  15th  to  29th  ten  to  twelve  hours  daily,  then  up  to  August 
1st  two  hours  daily  (one  hour  in  the  morning  and  one  hour  in 
the  afternoon).  Improvement  of  mobility  did  not  result.  The 
Roentgen  picture  taken  previous  to  his  discharge  seems  to  show 
a  bony  ankylosis  of  the  joint.  On  the  whole,  the  disease  seems 


163 

to  have  improved,  the  general  condition  of  the  patient  is  better. 
On  his  discharge,  August  2,  1902,  the  right  shoulder,  which  pre- 
viously was  sunk  in  and  atrophic,  was  at  least  as  arched  as  the  left 
one,  if  not  more  so.  The  right  arm  was  exactly  as  long  as  the 
left  one.  On  inspection  the  atrophy  of  the  musculature  seems  to 
have  disappeared,  mensuration  showed  that  the  right  upper  arm  was 
still  l/2  cm.  thinner  than  the  left  one.  The  previously  existing  pain- 
fulness,  especially  that  on  pressure  on  the  sulcus  intertubercularis, 
had  entirely  disappeared. 

This  result  surprised  me  very  much.  In  the  course  of  two  and 
one-half  months  the  shortening  of  2^  cm.  was  remedied  and  the 
atrophic  soft  parts,  though  the  shoulder-joint  could  not  be  used  on 
account  of  the  ankylosis,  to  all  appearances  became  as  large  as 
those  on  the  healthy  side.  That  the  lengthening  took  place  indeed 
and  is  not  due  to  an  error  in  measuring,  is  evident  from  the  two 
Roentgen  pictures  taken  on  admission  and  before  discharge  under 
the  same  conditions.  While  the  former  shows  atrophy  of  the 
epiphysis  as  compared  with  the  healthy  arm,  in  the  latter  can  be 
seen  a  bulky  epiphysis  which  is  broader  than  that  of  the  healthy 
side.  The  same  is  the  case  with  the  neighboring  part  of  the 
diaphysis.  To  be  sure,  measurement  with  the  compass  (the  pictures 
are  of  the  same  size)  shows  that  the  diseased  epiphysis  is  about 
1  cm.  lower  than  that  of  the  healthy  side  but,  at  any  rate,  this  is 
evened  up  by  its  greater  broadness  and  increased  growth  of  the 
diaphysis. 

One  should  think  that  this  is  a  pure  case  of  passive  nutrition  of 
an  atrophic  joint  by  hyperemia,  yet  I  do  not  believe  that  the  case 
is  to  be  thus  regarded,  for  in  addition  to  the  disappearance  of  the 
other  atrophies  that  of  the  muscles  of  the  fossa  supra-  and  infra- 
spinata  disappeared  also,  although  they  were  external  to  the  con- 
stricting rubber  tubing  and  not  at  all  affected  by  the  hyperemia. 
Therefore,  in  this  case  also  the  disappearance  of  the  atrophy  occurred 
in  connection  with  the  improvement  of  the  primary  disease. 

I  have  frequently  tried  to  nourish  the  entire  human 
being  in  a  different  manner.  As  is  well  known,  the  body 
is  stimulated  to  increased  formation  of  blood  by  with- 
drawal of  blood ;  the  successes  of  venesection  in  chlor- 
osis are  explained  in  this  manner.  I  have  tried  to  with- 
draw from  the  circulation  large  quantities  of  blood  in 
anemic  people  by  subjecting  larger  bodily  parts  to  stasis 
hyperemia'5  and  thus  to  stimulate  the  rest  of  the  body 
rendered  bloodless  towards  formation  of  blood.  To  be 
sure,  I  never  had  pure*  cases  but  have  employed  the 
method  only  when  it  was  indicated  because  of  a  different 
affection.  Thus,  if  we  had  -an  affected  ankle-joint  in  an 
anemic  patient,  the  stasis  bandage  was  applied  high  at 
the  thigh  without  bandaging  the  healthy  part  of  the  leg. 
I  am  under  the  impression — we  can  only  talk  here  of  im- 


164         NUTRITIVE  EFFECT  OF  HYPEREMIA 

pressions — that  I  have  succeeded  in  several  cases  in  im- 
proving and  increasing  the  blood,  and  it  may  pay  to 
keep  an  eye  on  this  in  the  future. 

INFLUENCE  OF  HYPEREMIA  ON   REGENERATION 

We  know  from  the  experiments  by  Ambroise  Pare,  v. 
Dumereicher,  Nicoladoni,  Helferich  and  Thomas  that  re- 
tarded formation  of  callus  can  be  considerably  increased 
by  institution  of  artificial  venous  hyperemia.  It  even 
seems  that  by  means  of  hyperemia  the  deficient  stimulus 
to  formation  of  bony  tissue  in  absent  formation  of  callus 
can  be  fanned  into  life.  At  this  time  the  influence  of 
hyperemia  on  the  healing  of  fractures  is  acknowledged. 

I  have  made  similar  experiences  in  inflamed,  especially 
in  acutely  and  subacutely  inflamed  joints.  Here  inflam- 
matory foci  under  stasis  hyperemia  change  into  stone- 
hard  connective  tissue  scars.  In  tuberculous  inflamma- 
tions one  can  observe  a  hardening  of  the  soft  tubercu- 
lous granulation  swelling  and  its  change  into  scars, 
although  naturally  this  takes  place  very  slowly.  Only 
in  a  few  isolated  cases,  which  we  will  describe,  the  stasis 
hyperemia  produces  a  sort  of  acute  inflammation  and  also 
changes  the  tuberculous  granulation  masses  into  tough, 
shrinking  connective  tissue  with  incredible  rapidity. 
This  kind  of  regeneration  and  rapid  formation  of  com- 
pleted connective  tissue  in  principle  is  the  same  process 
but,  in  my  opinion,  more  striking  and  more  convincing 
than  the  healing  of  a  pseudo-arthrosis.  For  we  can  see  the 
entire  process  take  place  before  our  eyes  in  a  few  days, 
and  by  the  sense  of  touch  can  follow  the  progress  of 
cicatrization.  This  extraordinarily  rapid  cicatrization  can 
be  explained  from  the  fact  that  in  those  inflammations 
is  already  present  the  first  stage  of  connective  tissue 
formation,  infiltration  of  small  cells  and  granulation. 

The  transformation  of  inflammatory  foci  in  connective 
tissue  scars  possibly  plays  a  great  role  in  the  cure  of 
infectious  diseases.  I  do  not  think  it  necessary  that  in 
all  cases  of  healing  of  joint  affected  with  an  infectious 
disease  the  stasis  hyperemia  kills  the  bacteria,  be  that 
by  serum  in  Buchner's  sense,  by  phagocytes  in  Metchni- 
kofFs  sense,  by  carbonic  acid  in  Hamburger's  sense  or 
by  other  as  yet  unknown  bactericidal  components  of 


NUTRITIVE  EFFECT  OF  HYPEREMIA         165 

the  blood,  but  believe  that  a  rapid  cicatrization  of  in- 
flammatory foci  encapsulates  the  bacteria  and  makes 
them  harmless.  We  know  from  experience  that  nature 
makes  use  of  this  method. 

Naturally  the  influence  of  hyperemia  on  the  formation 
of  callus  has  been  investigated  experimentally.  I  will 
not  discuss  the  numerous  experiments  by  means  of 
cutting  through  of  mixed  nerves  where,  in  addition  to  the 
sensible  and  motoric  paralysis  on  account  of  de- 
struction of  vasomotoric  fibers,  there  is  also  produced 
an  arterial  hyperemia.  I  believe  that  these  experiments 
have  but  a  limited  value  for  the  decision  of  our  ques- 
tion. For  in  addition  to  the  hyperemia  so  large  a  number 
of  unforeseen  changes  take  place  which  influence  healing 
that  it  is  difficult  to  say  whether  the  hyperemia  as  such 
exercises  any  influence  on  the  healing  of  the  bone-wound 
or  not.  This  is  noticeable  in  the  results  of  these  experi- 
ments (164)  ;  some  investigators  found  that  cutting  of 
the  nerve  furthers  the  formation  of  callus,  others  that  it 
retards  the  latter  and  again  others  assert  that  it  has  no  in- 
fluence whatever  on  the  course  of  the  healing.  For  the 
same  reason  I  have  not  considered  in  the  first  section  of 
this  chapter  Nasse's  (165)  much-discussed  contribution 
on  the  influence  of  nerve-section  on  the  nutrition  of  bone. 

That  these  experiments  can  not  be  used  for  our  ques- 
tion is  evident.  Samuel  (166)  has  given  us  the  experi- 
mental proof  that  here  unnatural  conditions  are  created 
for  regeneration.  He  cut  the  plexus  axillaris  of  the  wings 
of  doves  and  there  appeared  not  only  a  pronounced 
hyperemia  but  also  a  formation  of  a  large,  steadily  grow- 
ing vascular  net  at  the  place  of  feather  formation  in  the 
paralyzed  wings,  which  lasted  several  months.  The 
consequence,  however,  was  not  an  increase  but  a  diminu- 
tion of  the  growth  of  newly  forming  feathers,  which 
became  more  pronounced  as  the  paralysis  continued.  If, 
on  the  other  hand,  Samuel  ligated  the  axillary  artery 
on  an  otherwise  healthy  wing  there  appeared  for  the 
time  being  a  retardation  of  the  growth  of  feathers,  which 
again  increased  when  the  collateral  circulation  formed. 

The  only  contribution  which  can  be  used  for  our 
purpose  is  that  by  A.  Bum  (167).  who  instituted  stasis 
hyperemia  in  his  animals  in  the  same  manner  as  we  do 


166  NUTRITIVE    EFFECT   OF    HYPEREMIA 

in  our  patients  and  who  thus  studied  its  influence  on 
fractures.  As  rabbits  are  not  convenient  for  experiments 
with  stasis  hyperemia,  he  used  young  dogs  in  whom  he 
produced  fractures  of  the  diaphyses  of  both  tibiae.  The 
extremities  were  placed  in  plaster  of  Paris  casts  around 
the  foot  and  knee-joints  in  position  of  extension.  Com- 
mencing with  the  following  day,  daily  applications  of 
stasis  hyperemia  lasting  one  and  one-half  hours  were 
made  to  the  thigh  of  one  side.  After  rejecting  all  experi- 
ments which  permit  of  a  doubtful  meaning,  Bum  comes 
to  the  conclusion  that  the  callus  formation  on  the  side 
where  stasis  hyperemia  had  been  maintained,  had  un- 
doubtedly progressed  farther.  First  of  all,  the  periosteal 
callus  was  better  formed  in  several  cases,  also  the  medul- 
lary callus.  Whether  or  not  the  intermediary  callus  was 
furthered  by  the  hyperemia  could  not  be  decided.  The 
deposition  of  calcium  salts  in  the  callus  seemed  to  be  in- 
creased. On  the  other  hand,  Bum  found  that  only  when 
there  was  inclination  toward  good  formation  of  callus 
was  any  noteworthy  success  experienced  from  hyperemia. 

Except  Bum  I  know  of  but  one  more  experimenter — 
Samuel  (168) — who  has  experimentally  studied  the  effect 
of  stasis  hyperemia  on  regeneration,  especially  on  that  of 
feathers.  But  his  experiments  also  can  not  be  made  use 
of,  because  he  has  applied  high  degrees  of  stasis,  as  we 
never  dare  use  for  therapeutic  purposes.  This  has  the 
opposite  effect  from  that  used  in  practice.  He  found  that 
a  constrictor  applied  to  the  forearm  of  doves  produced 
a  small  yet  plainly  perceptible  retardation  of  growth  of 
the  newly  forming  feathers.  But  he  applied  the  con- 
strictor so  firmly  that  it  frequently  produced  gangrene  of 
the  entire  wing  or  at  best  suppurating  vesicles  and  eschar 
of  the  skin,  and  permitted  the  constrictor  to  remain  for 
a  prolonged  time.  Thus  he  produced  destruction  of 
nutrition  of  the  worst  kind  and  it  is  to  be  wondered 
that  by  it  the  growth  of  feathers  was  not  more  retarded. 

Long  ago  numerous  experiments  have  been  made  to 
learn  the  influence  of  arterial  hyperemia  on  the  processes 
of  regeneration.  I  will  omit  to  discuss  these  experiments 
(169)  in  which  by  the  cutting  of  mixed  nerves  in  the 
extremities  arterial  hyperemia  is  produced,  in  addition 
to  all  possible  grave  changes  of  the  tissues.  Of 


NUTRITIVE  EFFECT  OF  HYPEREMIA         167 

greater  value  are  those  experiments  where  by  means  of 
cutting  or  resection  of  the  sympathicus  of  the  neck  arte- 
rial hyperemia  of  one  half  of  the  head  is  established.  The 
majority  of  experimenters  have  worked  with  this  method 
but  have  reached  the  most  contradictory  results. 

Yirchow  (i/o)  applied  in  dogs  and  rabbits,  in  whom 
he  cut  through  the  sympathicus  on  one  side,  inflamma- 
tory stimuli  on  equal  places  in  both  sides  as  equally  in- 
tense in  degree  as  possible,  but  could  notice  no  difference 
in  the  course  of  the  inflammations.  From  this  and  other 
observations  he  concluded  "that  the  larger  or  lesser  intro- 
duction of  blood  to  a  part  is  not  as  important  for  the  nu- 
trition of  the  individual  elements  as  has  often  been  ac- 
cepted." 

On  the  other  hand,  Snellen  (171)  found  that  cutting 
through  the  sympathicus  accelerates  the  process  of  in- 
flammation, the  absorption  of  exsudates,  the  healing  and 
cicatrization  of  wounds  of  the  concerned  Half  of  the 
head. 

O.  Weber  (172)  confirms  Snellen's  experiments:  "If 
the  same  injury  be  inflicted  at  the  same  time  on  the  para- 
lyzed and  on  the  healthy  ear,  the  reaction  on  the  vaso- 
motorically  paralyzed  part  will  be  found  more  intense 
than  in  the  healthy  part.  It  does  not  matter  whether 
the  injury  consisted  in  the  introduction  of  a  pea  or  glass 
bead  in  a  cut  wound,  an  incised  wound,  or  the  application 
of  equal-sized  pieces  of  caustic  potash.  Healing  oc- 
curred more  rapidly  in  the  paralyzed  part,  as  the  forma- 
tion of  cells  and  vessels  takes  place  more  rapidly." 

These  investigations  rested  quietly  until  in  1881  Sin- 
itzin  (173)  resurrected  them  by  a  contribution.  From 
that  year  up  to  the  most  recent  time  a  series  of  investi- 
gations have  been  published  on  this  question  without 
an  understanding  being  reached.  Sinitzin  maintains  that 
the  hyperemia  following  the  removal  of  the  highest  sym- 
pathicus ganglion  gives  the  operated  side  greater  power 
of  resistance  to  foreign  and  neutral  substances.  Fine 
glass  threads  which  he  inserted  at  symmetrical  places  of 
both  cornea  produced  the  most  violent  inflammations  of 
conjunctiva,  cornea  and  iris,  ulceration  and  threatening 
panophthalmia,  but  on  the  operated  side  there  appeared 
either  no  reaction  whatever  or  a  very  slight  one.  If 


168         NUTRITIVE  EFFECT  OF  HYPEREMIA 

shortly  before  or  after  the  removal  of  the  highest  sym- 
pathicus ganglion  of  the  neck  the  trigeminus  was  cut 
in  the  cavity  of  the  skull,  the  known  disturbances  of 
nutrition,  neuroparalytic  keratitis,  ulcers  of  the  conjunc- 
tiva and  mucous  membrane  of  the  mouth,  did  not  appear. 
The  disturbances  of  nutrition,  even  though  far 
progressed,  can  be  cured  or  improved  when  the  sympa- 
thicus  ganglion  is  removed  afterwards.  This  occurred 
even  when  no  preventive  measures  were  undertaken  for 
the  operated  side ;  if,  however,  the  carotis  was  ligated  so 
that  a  hy.peremia  could  not  be  produced,  the  phenomena 
of  disturbed  nutrition  became  established. 

The  correctness  of  Sinitzin's  results  has  been  keenly 
disputed.  Eckhard  (174)  and  Senftleben  (175)  retested 
the  experiments,  and  both  found  that  the  removal  of  the 
uppermost  sympathicus  ganglion  has  no  influence  on  the 
establishment  and  course  of  disturbances  of  nutrition  fol- 
lowing cutting  of  the  trigeminus. 

Danilewski  (176)  produced  inflammation  in  the  ear  of 
a  rabbit,  and  excised  pieces  from  it.  One  to  two  days  later 
he  cut  through  the  sympathicus  and  made  the  following 
observations :  "The  reactive  hyperemia  produced  by 
croton  oil  equalizes  more  rapidly  on  that  side  in  which, 
owing  to  cutting  of  the  nerves,  there  was  larger  flux,  the 
inflamed  place  being  characterized  during  the  first 
twenty-four  hours  by  a  specially  intense  color.  If 
vesicles  occur,  with  transparent  or  pus-like  contents,  the 
inflammation  on  the  neurotomized  side  runs  a  more  pro- 
nounced and  violent  course,  the  accumulation  of  blood  is 
greater,  the  granulations  are  more  developed  and  hyper-^ 
emic.  The  course  of  the  inflammatory  process  on  the 
neurotomized  side  terminates  twice  as  rapidly  as  that 
of  the  other.  Healing  on  the  operated  side  frequently 
takes  place  without  loss  of  substance,  occasionally  even 
with  hyperplastic  granulation  in  the  form  of  regenera- 
tion. On  the  opposite  side  the  inflammation  terminates, 
as  a  rule,  with  incomplete  regeneration  or  more  or  less 
loss  of  substance.  Suppuration  on  the  neurotomized 
side  is  always  more  pronounced,  the  pus  having  the 
characteristics  of  the  pus  boninn  ct  landabile;  on  the  unaf- 
fected side  it  is  grayish,  watery,  semi-transparent,  and 
flocculent.  Necrosis  following  violent  irritation  takes 


NUTRITIVE   EFFECT  OF  HYPEREMIA  169 

place  exclusively  on  that  side  where  the  sympathicus  is 
intact." 

If  Danilewski  produced  the  inflammation  only  one  to 
two  days  after  the  cutting  of  the  sympathicus,  a  more  in- 
tense reaction  occurred  on  the  operated  side,  the  hyper- 
emia  was  more  pronounced,  suppuration  appeared  more 
freely  and  granulation  stronger.  Blood  effusions  could 
be  more  easily  produced  on  the  operated  side,  but  they 
were  again  more  rapidly  absorbed.  Punched  out  wound 
healed  twice  as  quickly  on  the  operated  side  than  on  the 
opposite  one,  the  regeneration  of  the  tissues  was  more 
complete,  while  violent  irritation  led  but  little  to  necro- 
sis. 

AYhile  thus  Danilewski  confirmed  the  experiments  of 
Snellen,  O.  Weber  and  Sinitzin,  Samuel  (177)  reached 
entirely  different  results.  "It  is  certain  that  arterial 
hyperemia,  after  the  cutting  of  nerve  trunks,  or  in  the 
immediate  neighborhood  of  inflammation  foci,  does  not 
cause  new  growth.  The  same  holds  good  for  venous 
hyperemia." 

In  a  later  contribution  Samuel  (178)  asserts  that  the 
observations  made  by  the  above-mentioned  physicians, 
contradictory  to  his  own  views,  prove  nothing,  because 
the  experimenters  have  made  use  of  the  other  apparently 
healthy  ear  of  the  animal  for  the  purpose  of  comparison. 
This  other  ear,  however,  is  not  normal,  for  it  becomes 
cool  and  anemic  after  the  operation  performed  on  the 
other  side.  Samuel  believes  that  the  operated  side  made 
use  of  the  blood  of  the  other,  thus  producing  the  anemia. 
Against  this  it  can  rightly  be  said  that  the  view  that 
local  excess  of  blood  mechanically  withdraws  blood  from 
the  neighborhood  for  some  time  can  be  considered  as 
proven  erroneous.  As,  however,  Samuel,  who  is  well 
known  as  a  reliable  observer,  has  demonstrated  macro- 
scopically  perceptible  pathologic  processes,  lasting  sink- 
ing of  temperature  on  the  apparently  healthy  side,  and 
as  he  also  relies  on  a  number  of  older  observers  who 
found  the  same  conditions,  there  can  be  no  doubt  as  to 
the  fact  itself.  In  all  probability  the  anemia  found  on 
the  apparently  healthy  side  is  due  to  reflectoric  influences. 
Samuel  made  use  of  entirely  healthy  animals  for  purpose 
of  comparison  and  found  that  the  phenomena  of  inflam- 


170  NUTRITIVE   EFFECT  OF  HYPEREMIA 

mation  in  sympathicus  paralysis  occurred  more  rapidly 
and  more  intensely,  also  that  they  lasted  a  good  deal 
longer.  To  be  sure,  Samuel  with  this  proof  has  not  suc- 
cessfully opposed  the  results  of  the  previous  investiga- 
tors, who  have  also  removed  the  upper  cervical  ganglion 
of  the  sympathicus,  for  Sinitzin  asserts  that  anemia  and 
coolness  on  the  non-operated  side  of  an  animal  does  not 
develop  if  the  removal  of  the  uppermost  ganglion  be 
added. 

•  The  most  recent  contribution  in  this  domain  by  Liek 
(179)  brings  an  absolute  confirmation  of  the  results  of 
.Snellen,  O.  Weber,  Sinitzin  and  Danilewski.  Liek 
showed  by  a  series  of  comparative  experiments  that 
Samuel's  above-mentioned  objection  to  the  interpretation 
of  the  healing  after  resection  of  the  sympathicus  is  not 
to  be  considered.  He  found  that  superficial  flat  and 
deep-incised  wounds  of  the  ear  of  a  rabbit  heal  much 
more  rapidly  when  the  sympathicus  was  cut  through  or 
the  uppermost  cervical  ganglion  was  removed  at  the 
same  time.  The  regeneration  took  place  proportionately 
to  the  degree  of  hyperemia. 

Lick's  contribution  offers,  for  this  reason,  the  strong- 
est proof  of  all  because  it  is  based  on  a  large  number 
of  experiments  and  in  spite  of  this  the  results  were  not 
contradictory,  and  because  any  objections  which  could 
be  raised  against  the  merits  of  the  experiments  have  been 
duly  considered  and  rejected. 

Penzo  (180)  demonstrated  in  a  new  manner  the  favor- 
able influence  of  hyperemia  on  regeneration.  He  con- 
structed an  ingenious  apparatus  in  which  he  could  keep 
warm  either  one  ear  or  limb  at  a  temperature  of  about 
38°  C,  while  the  other  could  be  cooled  to  a  temperature 
of  io  °  C.  The  animals  were  removed  from  the  appara- 
tus for  only  a  few  hours  daily.  It  was  found  that  the 
hyperemia  produced  by  the  warmth  considerably  accele- 
rated regeneration  in  open  and  subcutaneous  wounds, 
while  the  anemia  produced  by  the  cold  retarded  it.  Penzo 
also  experimented  with  these  agents  to  determine  their 
influence  on  fracture  of  the  ulna  in  rabbits.  Here  the 
difference  was  extraordinarily  pronounced.  While  on 
the  cold  side  after  seven  to  eight  days  not  even  the  be* 
ginning  of  regeneration  could  be  noticed,  the  fracture  on 


NUTRITIVE  EFFECT  OF   HYPEREMIA  171 

the  warmed  side  was  already  firmly  united  by  callus, 
which,  on  microscopic  examination,  proved  fully  formed. 

Thus  we  see  that  the  predominant  view  of  the  experi- 
menters is  that  artificial  active  hyperemia  considerably 
accelerates  regeneration.  If  we  consider  that  the  con- 
tributions which  base  on  a  large  number  of  experiments, 
very  plainly  show  the  same  result,  we  must  recognize 
this  as  fact  and  can  say:  While  the  favorable  influence 
of  hyperemia  on  physiologic  growth  of  the  organs  and 
nutrition  of  tissue  is  proved  only  in  regard  to  supporting 
tissue  and  cover  epithelium  (surface  epithelium)  and 
even  this  not  for  all  cases,  for  other  tissue  however,  be- 
ing at  least  very  doubtful,  it  can  not  be  doubted  that 
regeneration  is  promoted  by  active  and  passive  hyper- 
emia. 

I  can  not  leave  these  observations  without  asserting 
that  in  regeneration  this  influence  by  hyperemia  is  proven 
just  as  for  completed  tissues,  so  for  tissues  with  passive 
functions,  surface  epithelium  and  supporting  tissue,  for 
the  scars  consist  of  these.  The  fact  that  nerves  and  ves- 
sels form  in  the  scars  does  not  speak  against  it,  for 
without  them  new  growth  can  not  be  imagined.  We 
know  that  nerves  and  vessels  are  not  excessively  present 
in  scars  and  that  their  function  leaves  much  to  be  de- 
sired. 

The  effect  on  regeneration  by  agents  producing  hy- 
peremia has  been  utilized  for  a  long  time.  Thus,  heat  in 
the  form  of  moist  compresses,  poultices,  etc.,  has  been 
used  to  stimulate  weak  granulation.  For  the  same  pur- 
pose we  have  numerous  chemical  irritants,  e.  g.,  turpen- 
tine ointment,  camphor  wine,  and  nitrate  of  silver. 

Guyot's  (181)  incubators  are  reminded  by  Penzo's  ex- 
periments. This  physician  placed  wounded  limbs  in  an 
apparatus,  the  air  of  which  was  heated  to  36°.  The 
temperature  must  not  exceed  40°,  nor  fall  below  20°  C. 

We  can  count  here  also  the  treatment  of  frost-bite  by 
hyperemia  proposed  by  Ritter  (182).  Ritter  found  most 
effective  the  active  hyperemia  produced  by  hot  air.  One 
could  conclude  from  this  that  the  vascular  paralysis  and 
venous  stasis  which  were  accepted  as  conditions  pro- 
duced by  the  freezing,  were  removed.  This  view  is  re- 
jected by  Ritter's  observations,  which  show  that  good 


172  NUTRITIVE   EFFECT   OF   HYPEREMIA 

results  are  also  obtained  with  artificial  stasis  hyperemia. 
For  this  reason  Ritter  thinks  that  the  hyperemia  effects 
a  regeneration  of  the  cells  damaged  or  destroyed  by  the 
freezing.  He  does  not,  as  is  customary,  look  upon  the 
freezing  hyperemia  as  something  obnoxious  which  should 
be  combated  but,  on  the  contrary,  as  a  useful  and  natural 
reaction  of  the  body  to  the  injury  which,  in  the  ma- 
jority of  instances,  should  be  supported.  That  really 
both  forms  of  hyperemia  have  a  favorable  effect  on  the 
healing  of  frost-bite,  I  have  become  convinced  by  Ritter's 
case. 

I,  myself,  in  the  beginning  of  my  experiments  with 
hyperemia,  have  repeatedly  treated  ulcers  which  have 
not  healed  by  other  remedies,  with  hot  air,  and  I  believe 
that  the  successes  of  Ullmann  (Chapter  XIII.),  with  in- 
fectious ulcers,  were  due  more  to  this  effect  of  the  active 
hyperemia  than  to  its  bactericidal  influence,  as  Ullmann 
believes. 

In  conclusion  we  must  discuss  the  question,  which 
form  of  hyperemia  best  supports  the  building  up  and 
regeneration  of  the  tissues?  I  believe  the  majority 
of  physicians  will  answer  without  much  think- 
ing, "the  active  arterial  hyperemia."  In  numberless 
contributions  one  can  read  that  "an  improvement  of  the 
circulation"  and  removal  of  blood-stoppage  naturally 
have  a  favorable  influence  on  the  nutrition.  The"  obser- 
vation that  the  functional  hyperemia  accompanying  the 
activity  of  the  organs  is  active,  seems  to  support  this 
view.  In  reality  this  view  is  not  at  all  proven  and  if  we 
here  permit  our  school-mistress,  Nature,  to  talk,  and 
accept  her  institutions  as  rational  we  will  come  to  a  dia- 
metrically opposed  opinion.  It  has  been  frequently  em- 
phasized that  nowhere  in  born  man  can  there  be  seen  a 
more  pronounced  regeneration  than  in  inflammation,  nay, 
that  this  inflammatory  regeneration,  as  shown  by  Wei- 
gert,  overreaches  the  mark,  producing  in  a  short  time  in 
place  of  the  injured  tissue  an  excess  of  new  one,  so  that 
one  is  justified  in  speaking  of  an  inflammatory  hyper- 
trophy. Inflammatory  hyperemia,  however,  is  not  active 
but  passive.  And  if  we  turn  to  the  most  moderate  re- 
generation which  we  know  of,  the  development  of  the 
fertilized  ovum  to  an  embryo  and  that  of  the  latter  to  a 


NUTRITIVE   EFFECT  OF  HYPEREMIA  173 

ripe  fetus,  \ve  well  observe,  as  has  been  shown  by 
Bonnet's  (183)  investigations,  the  most  magnificent 
stasis  hyperemia  that  we  can  see  anywhere  in  the  human 
body.  The  blood  current  in  the  wide  blood-spaces  of 
the  placenta  is  slowed  to  such  an  extent  that  intense 
edema  and  extensive  hemorrhages  develop  in  the  tissues 
of  the  placenta.  According  to  Bonnet,  the  embryo 
draws  most  of  its  food  from  the  slowly  moving  blood, 
especially  from  the  edema  and  from  the  transuded  de- 
composing blood.  Also  the  rest  of  the  food  is  created 
by  the  stased  blood  through  dissolution  of  tissue  com- 
ponents from  the  mother. 

As  regards  the  function  of  the  tissues  we  have  to  deal 
with  entirely  different  processes.  Work  is  done  princi- 
pally by  oxidation  of  the  tissues  and  for  this  a  quick 
blood-stream  is  necessary,  which  must  always  supply 
new  blood  rich  in  oxygen.  For  undisturbed  work  it  is 
furthermore  necessary  that  the  combustible  products 
which  act  intoxicating  and  paralyzing  on  the  active 
organ,  be  continually  washed  away  and  this,  too,  is  best 
accomplished  by  a  powerful  rapidly  flowing  blood- 
stream. 

I  therefore  believe  we  are  justified  in  establishing  the 
following  as  an  axiom  :  Functional  hyperemia  is  active ; 
that  which  serves  to  build  up  tissues  in  all  probability 
passive.  From  this  must  not  be  concluded  that  the  cell, 
which  intends  to  enlarge  or  increase  in  consequence  of  an 
unknown  stimulus,  can  not  take  the  necessary  food  from 
a  rapidly  flowing  blood-current.  Much  seems  to  speak 
for  it  that  function,  accompanied  by  active  hyperemia, 
leads  to  enlargement  of  the  active  parts  and  that  a  few 
of  the  above-cited  observations  and  experiments  show 
that  also  active  hyperemia  favorably  influences  regenera- 
tion. But,  first  of  all,  the  building  of  the  tissues  that 
leads  to  functional  hypertrophy  proceeds  so  slowly  that 
it  can  not  in  the  least  be  measured  with  the  great  rapidity 
of  inflammatory  and  embryonal  regeneration,  and  again 
we  even  do  not  know  whether  in  those  cases  the  eating 
cell  really  takes  its  food  from  an  accelerated  juice-stream. 
For  the  inflammatory  hyperemia,  too,  is  originally  active, 
and  the  inflammatory  irritation  changes  the  originally 
rapid  into  slower  blood-current.  It  is  not  at  all  improb- 


174         NUTRITIVE  EFFECT  OF  HYPEREMIA 

able  that  the  unknown  growth  stimulus  possesses  the 
same  property. 

The  functional  hypertrophy  shows  a  great  analogy 
with  the  inflammatory  one.  Here,  as  there,  an  injury 
precedes  the  increase  and  enlargement  of  the  tissue  cells, 
which  causes  the  hypertrophy.  Thus  Weigert  (184),  the 
discoverer  of  inflammatory  tissue  hypertrophy,  has  ex- 
pressed the  view  that  the  exercise  hypertrophy  is  an  in- 
direct consequence  of  function,  because  it  is  the  latter 
which  leads  to  injury  of  cells  and  this  to  hypertrophy. 

The  circumstance  that  the  work  of  the  tissues  leads  to 
active  hyperemia,  does  by  no  means  indicate  that  the 
latter  is  essential  for  the  following  formation  of  new  tis- 
sue. In  all  probability  this,  too,  will  take  its  food  from 
a  slowed  blood-current,  for  we  now  know  that  even  the 
decomposition  of  our  own  body  tissues  produces  in- 
flammatory phenomena.  One  thinks  of  the  subcutane- 
ous blood-effusions,  which  produce  hyperemia  and  in- 
tense edema,  and  of  fever  and  albuminuria,  which  has 
been  observed  during  its  resorption  just  as  after  vigorous 
physical  exertion  which  led  to  a  pronounced  decomposi- 
tion of  body  tissues.  Hypertrophy,  however,  does  not 
develop  during  labor  but  in  the  intervals  of  rest  after- 
wards and  the  sensation  of  fatigue  prevents  us  from  con- 
tinuing labor  after  great  physical  exertion.  It  seems  to  me 
very  probable  that  considering  the  relationship  of  both 
processes,  the  functional  and  inflammatory  hypertrophy 
are  both  associated  with  a  passive  hyperemia. 

These  ideas  are  presented  especially  to  those  physi- 
cians who  have  no  objection  to  an  artificial  active  hyper- 
emia, but — as  has  been  done  by  several  of  my  immediate 
colleagues — have  opposed  my  efforts  to  cure  diverse  dis- 
eases with  artificial  passive  hyperemia,  an  an  excres- 
cense  of  a  mad  phantasy,  but  who  also  know  of  no 
other  reason  than  that  passive  hyperemia  "self-evidently" 
represents  a  grave  disturbance  of  nutrition. 


C       SPECIAL   PART 


TREATMENT    OF    DIVERSE    DISEASES    WITH 
-  HYPEREMIA 


CHAPTER  XVII 

INTRODUCTORY 

In  the  following  chapters,  which  are  to  treat  on  the 
therapy  of  diverse  diseases  with  artificially  produced  hy- 
peremia,  I  do  not  intend  to  cite  and  discuss  all  treated 
cases.  This  alone  would  fill  a  large  volume,  since  the 
number  of  cases  exceeds  by  far  the  figure  1,000,  and 
besides,  I  could  not  do  it  for  the  reason  that  a  large  part 
of  these  cases  are  not  now  accessible. 

I  am  here  especially  concerned  in  the  dis.cussion  of  the 
technic  for  those  diseases  which  have  been  successfully 
treated  with  hyperemia.  I  will  cite  histories  of  cases 
only  where  my  assertions  have  not  been  substantiated  by 
suitable  examples  hereto-fore. 

I  also  deem  it  superfluous  to  report  a  series  of  cases 
which  we  have  experimentally  treated  with  hyperemia 
but  where  our  experience  is  so  meager  or  so  deficient  that 
positive  conclusions  can  not  be  reached. 

A  few  general  remarks  are  in  order.  Any  remedy,  be 
it  chemical  or  physical,  acts  differently  in  proportion  to 
the  dose  in  which  it  is  administered.  A  medicinal 
remedy  useful  in  a  small  dose  may  become  injurious, 
even  fatal,  as  the  size  of  the  dose  is  increased.  H.  Schulz 
(185)  has  shown  that  there  exists  in  this  respect  a  regu- 
larity like  a  law.  He  proceeded  from  the  biologic  axiom 
established  by  Arndt  for  normal  conditions,  that  is  based 
on  a  generalization  of  Pfliiger's  "twitch  law,"  as  follows: 
"Small  stimuli  fan  .the  activity  of  life,  medium  large  ones 
further  it,  strong  ones  impede  it,  and  the  strongest  ones 
destroy  it."  Schulz  emphasizes  that  this  law  holds  good 
also  for  tha  effect  of  medicines  and  poisons,  and  that  it 

175 


176  INTRODUCTORY 

does  not  lose  its  validity  when  applied  to  pathologic  con- 
ditions. For  the  latter  case  it  must  be  borne  in  mind 
that  for  diseased  organs  the  stimuli  may  be  strong  when 
they  can  scarcely  be  considered  as  such  for  healthy  or- 
gans. 

This  difference  in  effect  on  the  body  evidently  holds 
good  also  for  the  physical  remedies,  perhaps  to  a  greater 
degree  than  for  the  medicinal  remedies  having  not  very 
strong  an  effect.  One  need  only  think  of  cold  water, 
where  success  depends  entirely  on  the  intensity  and 
length  of  application,  the  least  error  being  sufficient  to 
change  the  healing  effect  into  one  apt  to  produce  sick- 
ness. 

If  we  consider  the  two  methods*  principally  treated  in 
this  book,  the  active  hyperemia  by  hot  air  and  the  pas- 
sive by  stasis  with  a  bandage  or  suction  apparatus,  we 
come  to  the  same  conclusion.  I  have  mentioned  that 
the  former,  applied  daily  one  or  at  most  two  hours,  is 
one  of  the,  most  important  absorbing  agents,  and  have 
shown  this  effect  principally  in  the  absorption  of  ede- 
mata. On  the  other  hand,  I  have  shown  in  my 
first  and  larger  contribution  in  1893  that  hot  air  of  100°  C. 
applied  to  a  portion  of  the  body  for  seven  to  ten  hours 
produces  intense  forms  of  edema. 

Stasis  hyperemia  in  a  medium  degree  is  one  of  the 
best  pain-relieving  agents  in  diverse  affections ;  if  an  ex- 
cessive degree  be  applied,  it,  on  the  contrary,  produces 
violent  pain  and  the  most  disagreeable  sensations.  The 
same  method  in  a  medium  degree  again  favorably  affects 
a  number  of  acute  and  chronic  local  infectious  diseases ; 
if,  however,  it  be  applied  too  intensely  it  injuries  in 
the  same  diseases,  or  even  produces  them.  If  we  wish 
to  use  our  agents  against  dis-ease  we  must  always  remem- 
ber this,  and  by  experience  must  ascertain  in  what  de- 
gree and  of  what  duration  they  may  and  can  be  applied  in 
each  individual  disease.  We  also  must  consider  that  just 
as  do  medicinal  substances,  our  agents  produce  vari- 
able reactions  in  different  individuals ;  that  what  is  to 
one  a  weak  stimulus  may  be  a  strong  one  to  another. 

*Artificial  hyperemia  stands  between  a  chemical  and  physical 
agent;  though  we  produce  it  in  a  simple  physical  manner  and  re- 
sorption,  for  instance,  is  a  physical  process,  the  main  effects,  how- 
ever, we  must  consider  as  chemical  in  character. 


CHAPTER  XVIII 

TREATMENT    OF    TUBERCULOSIS 

I  begin  with  the  treatment  of  joint  tuberculosis  be- 
cause it  was  the  first  disease  against  which  I  applied 
hyperemia.  In  my  opinion,  passive  hyperemia  only  need 
be  considered  as  a  therapeutic  agent  for  it.  I  consider 
intense  active  hyperemia  here  as  very  injurious,  as  al- 
ready repeatedly  discussed ;  as  a  general  rule,  I  have  seen 
turns  for  the  worse  after  its  application. 

I  hit  upon  the  idea  of  applying  hyperemia  against  tu- 
berculosis by  the  following  observations  made  by  older 
physicians:  Farre  and  Travers,  in  1815,  and  Louis,  in 
1826,  called  attention  to  the  frequent  appearance  of  pul- 
monary stenosis  in  phthisis,  explaining  it  by  the  pro- 
nounced anemia  of  the  lungs  which  this  form  of  heart  dis- 
ease produces.  The  observations  of  those  physicians 
have  been  confirmed  without  exception,  so  that  Frerichs 
(186)  could  pronounce  the  dictum:  "Pulmonary  tuber- 
culosis, be  the  relation  of  this  disease  to  tuberculosis  as 
it  may,  is  the  usual  end  in  diseases  of  the  pulmonary 
artery."  On  the  other  hand,  Rokitansky  (187)  maintains 
that  diseases  of  the  heart  accompanied  by  fullness  of 
blood  in  the  lungs  offer  immunity  against  tuberculosis. 
Here  follow  his  own  words :  "A  relation  of  hyper- 
trophy of  the  heart  to  tuberculous  disease  is  the  result 
of  numerous  observations.  In  a  number  of  one  hundred 
and  forty-three  cases  (simple,  -eccentric,  as  well  as  con- 
centric hypertrophy),  I  find  that  in  fifteen  cases  there  is  a 
now  extinct  tuberculosis  of  the  lungs.  In  all  other  cases — 
persons  of  variable  age,  sex,  occupation,  etc. — there  never 
was  a  tubercle,  from  which  can  be  concluded  that  both 
diseased  conditions  can  not  exist  at  the  same  time  in 
one  and  the  same  individual,  and  especially  that  in  the 
presence  of  the  named  disease  of  the  heart  no  tubercu- 
losis, especially  pulmonary  tuberculosis,  can  develop." 

The  same  immunity  against  tuberculosis  Rokitansky 
ascribed  to  people  with  distortions  of  the  spine,  in  whom, 
as  is  well  known,  pronounced  stases  develop  in  the  circu- 
lation of  the  lungs.  Here,  too,  I  will  let  Rokitansky 
speak :  "At  first  we  were  surprised  by  the  absence  of 

12  177 


178  TREATMENT  OF  TUBERCULOSIS 

any  trace  of  suspected  phthisis  pulmonalis  in  the  corpses 
of  persons  with  distorted  spines ;  after  these  observations 
have  increased  to  a  considerable  number  the  noteworthy 
find  in  each  individual  case  because  of  its  constancy,  the 
rule  follows  that  in  distortions  of  the  spine  tuberculosis, 
and  especially  pulmonary  tuberculosis,  does  not  occur." 

Rokitansky  gives  for  this  statistic  numbers.  He 
found  among  fifty  of  his  post-mortems  of  concerned  cases 
no  more  than  three  in  which  tuberculosis  was  present  at 
the  same  time,  cases  in  which  insignificant  distortions 
and  deformities  of  the  thorax  only  were  present. 

Rokitansky's  observations  have  been  repeatedly  con- 
firmed but  have  also  been  much  attacked.  I  will  not  cite 
from  the  rich  literature  the  contributions  by  the  followers 
and  opponents  of  Rokitansky's  doctrine.  I  only  remark 
that  the  large  majority  of  physicians  who  have  expressed 
themselves  on  this  do  not  allow  Rokitansky's  assertions 
to  stand  in  so  sweeping  a  way  as  he  has  expressed  them, 
but  nevertheless  acknowledge  the  correctness  of  the 
principle  and  admit  a  relative  immunity  of  stased  lungs 
against  tuberculosis.  Those  of  the  readers  who  are  in- 
terested in  this  question  I  refer  to  a  portion  of  the  litera- 
ture found  in  the  bibliographic  references  (188-200  inc.). 
I  can  well  omit  to  discuss  those  observations,  for  they 
were  for  me  only  the  inspiration  to  treat  a  single  disease 
with  hyperemia.  The  experience  I  gained  at  it  compelled 
me  to  apply  this  treatment  to  numerous  diseases,  turning 
the  whole  question  into  a  different  domain. 

My  first  contribution  on  the  treatment  of  tuberculosis 
with  hyperemia  I  published  in  the  year  1892  (201).  I 
described  it  in  detail  in  larger  contributions  which  ap- 
peared in  1893  (202)  and  1894  (203).  My  last  publica- 
tion on  the  subject  appeared  in  1895  (204).  Since  then 
I  have  published  no  further  details  on  the  treatment 
of  tuberculosis  because  we  were  continuously  occupied 
with  experiments  to  discover  the  right  technic  of  stasis 
hyperemia  for  this  disease ;  for  with  no  other  affection 
at  all  suitable  to  treatment  with  hyperemia  did  we  experi- 
ence so  much  difficulty  in  working  out  the  technic  as 
with  tuberculosis.  Of  special  importance  here  is  the 
fact  that  an  incorrect  application  of  stasis  hyperemia 
may  become  very  injurious.  It  is  therefore  important, 


TREATMENT  OF  TUBERCULOSIS  179 

if  this  remedy  is  to  be  generally  used  by  the  general 
practitioner,  to  give  plain  and  exact  rules  for  the  appli- 
cation of  the  process  and  to  so  arrange  them  that  even 
the  inexperienced  can  do  no  harm  .  I  believe  that  we  have 
now  so  perfected  and  simplified  the  technic  after  many1 
years  of  experimentation  that  harm  from  this  agent  can 
be  avoided.  I  deem  it  advisable  to  briefly  describe  the 
process  of  the  development  of  the  technic. 

In  the  beginning  I  made  daily  applications  of  stasis 
hyperemia  of  one  or  several  hours'  duration,  but  soon 
changed  to  a  prolonged  application.  (The  process  has 
already  been  described  in  Chapter  VII.)  The  bandage 
was  worn  day  and  night,  but  twice  daily  the  bandage 
was  changed  to  different  places  to  avoid  pressure.; 
Usually  it  was  removed  only  once  a  week.  I  then  per- 
mitted the  affected  parts,  which  were  in  a  condition  of 
swelling  and  edema,  to  regain  their  size  in  order  to. 
demonstrate  and  watch  any  change  in  the  diseased  limb. 
The  results  of  the  treatment  were  variable,  splendid  suc- 
cesses alternating  with  failures,  or  such  cases  where. 
stasis  hyperemia  alone  proved  inefficient  necessitating1 
other  conservative  or  operative  measures.  In  all  cases 
the  improvement  following  the  first  application  of  the 
remedy  was  striking;  pain  disappeared,  existing  contrac- 
tions were  loosened,  even  the  mobility  of  diseased  joints 
improved  considerably.  Tuberculous  patients  who  pre- 
viously could  make  no  use  whatever  of  their  diseased 
limbs  were  frequently  able  after  a  few  days  to  undertake 
some  light  work.  But  I  had  to  report  to  the  Surgical 
Congress,  which  met  in  1894,  some  disagreeable  and  dan- 
gerous accidents  produced  by  the  stasis  hyperemia  in 
the  tuberculous  limbs.  The  most  frequent  complication 
was  the  occurrence  of  cold  abscesses,  which  evidently 
were  furthered  to  a  great  degree  by  the  stasis  hyperemia. 
Seldom  the  abscesses  appeared  without  symptoms,  in  the 
majority  of  the  cases  the  course  was  highly  character- 
istic :  After  an  immediate  improvement  in  the  tuber- 
culous joint  the  patient  suddenly  complained  of  pains 
which  appeared  in  a  definite  place,  sensitiveness  against 
pressure  in  that  place  being  great.  On  removal  of  the 
bandage  after  the  edema  and  swelling  had  subsided,  the 
incipient  abscess  could  be  recognized  by  the  evident 


180  TREATMENT  OF  TUBERCULOSIS 

fluctuation.  The  latter,  at  any  rate,  appeared  when  the 
stasis  hyperemia  was  continued.  Occasionally  the  ab- 
scesses under  the  hyperemia  grew  more  rapidly  and  be- 
came more  numerous  than  we  have  ever  seen  them  before, 
so  that  no  doubt  existed  that  they  were  produced  by  the 
stasis  hyperemia. 

I  have  assumed  that  this  per  se  is  no  bad  sign.  I  saw 
in  the  appearance  of  the  abscesses  an  effort  on  the  part 
of  nature  to  melt  in  and  to  expel  dead,  useless  and  dis- 
eased tissue.  I  even  gave  rules  how  to  treat  these  cold 
abscesses  and  recommended  aspiration  and  subsequent 
filling  with  iodoform  .glycerin.  I  believed  that  both 
remedies,  stasis  hyperemia  and  iodoform,  happily  sup- 
ported each  other  in  so  far  as  the  former  led  partially  to 
cicatrization,  partially  to  cold  abscesses  of  such  foci 
as  could  not  be  reached  by  the  iodoform.  As  regards 
the  change  into  cold  abscesses  we  could  combat  them 
more  successfully  than  any  other  phenomenon  of  tuber- 
culosis with  iodoform.  But  I  have  later  concluded 
that  the  production  of  large  cold  abscesses  by  stasis 
hyperemia  in  the  majority  of  cases  doubtlessly  means  a 
turn  for  the  worse,  of  the  disease,  for  they  appear  so  fre- 
quently and  grow  so  rapidly  that  one  can  not  master 
them. 

The  other  ill  experience  we  made  was  the  develop- 
ment of  large  granulating  masses  which,  as  a  rule,  ap- 
peared in  open  ulcers  and  fistulse  of  open  joint  tuber- 
culosis, but  sometimes  also  in  subcutaneous  covered  ones, 
finally  breaking  these  through.  Occasionally  I  saw  after 
a  continuance  of  the  remedy  the  desired  shrinking  and 
cicatrization  of  the  excessive  granulation  ;  often,  however, 
it  progressed  unhindered  and  compelled  us  to  stop  the 
treatment  and  to  replace  it  by  bloody  operations.  The 
worst,  however,  was  that  in  open  joint  tuberculosis,  evi- 
dently under  the  influence  of  the  remedy,  developed  the 
most  violent  acute  inflammations,  of  which  we  know  that 
they  become  associated  with  chronic  edemata.  I  then 
had  to  report  hot  abscesses,  lymphangitis,  adenitis, 
erysipelas,  and  erysipeloid  affections  of  the  skin,  even  a 
case  of  suppuration  of  the  ankle-joint  with  a  lethal  end 
from  sepsis.  However,  these  bad  complications  were  ob- 
served only  in  grave  forms  of  tuberculosis.  I  saw  them 


TREATMENT   OF   TUBERCULOSIS  181 

only  in  connection  with  large,  tuberculous  ulcers,  and 
especially  in  large  joint  cavities  which  were  filled  with 
pus  and  which  communicated  with  the  outside  by  means 
of  a  fistula. 

As  a  rule,  errors  in  the  technic  of  bandaging  or  too 
careless  use  of  the  limbs,  which  was  permitted  by  us  as 
much  as  the  pain  permitted  it,  could  be  demonstrated. 
But  on  objectively  considering  the  cases  we  could  not 
get  away  from  the  conviction  that  the  applied  remedy  was 
blameless.  I,  therefore,  then  advised  to  dress  asepti- 
cally  cases  of  open  joint  tuberculosis  which  were  to  be 
treated  with  stasis  hyperemia,  and  to  permit  the  use  of 
the  limbs  either  not  at  all  or  to  a  very  limited  extent. 
I  furthermore  reported  that  even  in  cases  running  a 
favorable  course  stasis  hyperemia  alone  did  not  lead  to 
our  goal.  Frequently  we  had  to  make  use  of  conserva- 
tive methods,  extension  bandages,  plaster  of  paris 
casts,  iodoform  injections,  etc.,  or  even  to  resort  to  more 
or  less  important  operations. 

Now  it  seems  reasonable  to  assume  that  if  the  same 
remedy  once  is  followed  by  the  most  brilliant  success, 
while  another  time  it  leads  to  a  grave  failure,  it  was  cor- 
rectly applied  in  the  first  case  and  falsely  in  the  second. 
This  conclusion,  I,  too,  have  drawn  from  my  experience. 
It  struck  me  as  significant  that  the  stasis  hyperemia  was 
followed  by  the  best  results  in  tuberculosis  of  the  shoul- 
der joint,  where  it  can  be  applied  only  with  comparative 
difficulty,  and  in  a  few  cases  of  tuberculosis  of  the  testes. 
In  both  the  locality,  as  I  have  already  said,  does  not  per- 
mit a  prolonged  application  of  the  hyperemia.  At  most 
the  latter  can  be  used  twelve  hours  daily  because  the 
place  of  constriction  can  not  be  changed,  thus,  if  applied 
for  too  prolonged  a  time,  producing  disagreeable  phe- 
nomena of  pressure. 

I  have  furthermore  observed  that  after  prolonged  ap- 
plication of  the  stasis  hyperemia  edema  becomes  promi- 
nent and  the  hyperemia  becomes  less  apparent.  Thus, 
a  chronic  edema  had  formed,  which  was  positively  harm- 
ful for  the  production  of  prolonged  hyperemia.  I,  there- 
fore, proceeded  in  this  way :  I  applied  prolonged  stasis 
hyperemia  only  for  a  few  days,  then  ordering  intermis- 
sions, which  were  lengthened  in  proportion  to  the  im- 


182  TREATMENT  OF  TUBERCULOSIS 

provement  of  the  cases  until  finally  the  method  was  ap- 
plied only  one  hour  daily. 

I  also  established  that  that  form  of  stasis  hyperemia 
which  so  influenced  the  circulation  that  intense  lividity 
and  diminution  of  the  temperature  of  the  skin  were  pro- 
duced in  the  corresponding  part  and  especially  that  stasis 
which  led  to  pain  and  real  inconvenience  are  noxious.  I, 
therefore,  prescribed: 

i.  Stasis  must  never  produce  pain,  otherwise  it  is 
either  improperly  applied  or  the  case  is  not  suited  for 
this  agent  and  must  be  "treated  in  a  different  manner. 

2..  The  stasis  must  not  be  cold,  it  must  not  reduce  the 
temperature  of  the  skin  to  such  an  extent  that  it  feels 
colder  than  the  skin  of  the  other  extremity.  It  is  favor- 
able for  the  course  of  the  tuberculosis  when  the  stasis, 
'on  the  contrary,  can  so  be  applied  that  the  temperature' 
of  the  skin  becomes  elevated  and  the  locality  exposed  to 
the  remedy  makes  the  impression  of  an  acute  inflamma- 
tion. 

After  the  establishment  of  these  rules,  the  dangerous 
complications,  the  grave  acute  inflammations,  disap- 
peared. But  while  the  first  rule  can  be  easily  followed, 
for  we  need  only  tell  the  patient  to  either  advise  us  or 
himself  loosen  the  bandage  as  soon  as  he  feels  the  least 
pain  or  paresthesia  in  the  limb,  the  second  rule  is  exe- 
cuted only  with  great  difficulty.  While  it  is  easy  to 
produce  hot  stasis  in  acutely  or  subacutely  inflamed 
limbs,  this  proves  a  quick  task  in  chronic  tuberculosis, 
and  what  is  more  difficult  yet  is  to  maintain  the  stasis 
after  it  has  once  been  produced,  Thus,  the  cases  of  joint 
tuberculosis  treated  with  stasis  hyperemia  required  great 
care  and  though  the  results  improved  the  formation  of 
cold  abscesses  did  not  fail  to  appear. 

We  then  reduced  more  and  more  the  duration  of  the 
daily  applied  stasis.  We  were  especially  influenced  in 
this  by  Notzel's  above-mentioned  contribution  in  which 
it  was  proven  experimentally  that  the  chronic  edema 
which  develops  after  prolonged  stasis  is  just  as  harmful 
to  the  course  of  infectious  diseases  as  is  the  acute  stasis 
useful.  In  shortening  the  time  of  application  of  the  rem- 
edy, I  followed  somewhat  this  plan :  In  the  first  few 
days  hot  stasis  is  instituted  seven  to  twelve  hours  daily 


TREATMENT  OF  TUBERCULOSIS  183 

until  the  painfulness  of  the  joints  is  considerably  dimin- 
ished. Then  the  time  is  reduced  one  half  and  gradually 
reduced  still  more  until  after  a  few  weeks  or  months 
the  stasis  hyperemia  is  applied  but  one  hour  daily.  As 
an  example  for  this  method  of  treatment,  I  cite  the  fol- 
lowing two  cases : 

1.  A  child,  seven  years  old,  from  a  tubercular  family,  commenced 
to  suffer  in  June,  1899,  from  pain  in  the  right  wrist-joint,  which 
gradually  increased  until  in  the  winter  of  the  same  year  the  joint 
became  swollen  and  stiff.  Passive  motions  and  massage  undertaken 
by  a  physician  aggravated  the  trouble. 

March  20,  1900,  I  found  the  right  wrist-joint  evenly  swollen, 
having  a  circumference  \l/2  cm.  larger  than  the  left  joint.  Flexion 
and  extension  were  practically  suspended,  supination  somewhat 
limited.  The  fingers  were  fairly  movable.  The  right  forearm  was 
atrophied.  The  joint  was  sensitive  to  pressure  in  two  places.  Fluor- 
oscopy  showed  confluent  carpal  bones  so  that  their  outlines  could 
not  be  recognized. 

From  March  20th  to  October  1st  I  applied  stasis  seven  to  twelve 
hours  daily  with  repeated  intermissions  of  eight  days.  While  the 
bandage  was  removed  the  limb  was  kept  in  an  elevated  position 
several  hours. 

Hyperemia  was  continued  from  two  to  three  hours  daily  from 
October,  1900,  to  March,  1901.  Then  the  treatment  was  discon- 
tinued. The  joint  improved  rapidly,  especially  as  far  as  mobility 
and  pain  were  concerned.  However,  in  October,  1900,  swelling 
was  present  about  as  much  as  before  and  examination  with  the 
Roentgen  rays  showed  yet  a  confluence  of  the  carpal  bones,  though 
a  brightening  of  the  picture  could  be  noticed. 

March  8,  1902,  I  examined  the  child  for  the  last  time.  I  found 
full  "mobility  of  the  right  wrist-joint  and  full  function  without  any 
limitation.  Measurement  showed  that  the  circumference  of  both 
joints  was  alike.  The  child  used  the  right  arm  again  more  than 
the  left  one,  for  which  reason  the  previously  established  atrophy 
of  the  right  forearm  had  not  only  disappeared,  but  even  had  a  cir- 
cumference at  the  thickest  place  exceeding  by  l/2  cm.  that  of  the 
left  arm.  The  child  used  its  hand  throughout  the  entire  treatment 
in  the  beginning  as  much  as  the  pains  permitted. 

A  Roentgen  picture  taken  March  18,  1902,  shows  absolutely  nor- 
mal bones. 

2.  A  child,  four  years  old,  of  a  tubercular  family,  was  attacked 
by  tuberculosis  of  the  left  wrist-joint  in  the  winter  of  1899.  Several 
cold  abscesses  developed,  which  were  incised  by  a  physician. 

I  saw  the  child  July  12,  1901,  and  noted  the  following  condi- 
tion: The  left  wrist-joint  is  fusiformly  swollen,  on  the  back  of 
the  hand  is  an  ulcer  about  as  large  as  a  dime  and  several  fistulae 
leading  to  rough  bones.  The  hand  hangs  in  flexed  contraction  and 
subluxated ;  motions  are  considerably  limited. 

Stasis  hyperemia  was  applied  from  eight  to  twelve  hours  daily 
from  July  12,  1901,  to  April  1,  1902,  with  numerous  intermissions 


184  TREATMENT  OF  TUBERCULOSIS 

of  one  to  several  days'  duration ;  from  April  1  to  August  23,  1902, 
stasis  hyperemia  was  applied  one  hour  daily.  The  disease  improved 
slowly,  but  a  successive  progress  could  be  noticed. 

August  23,  1902,  treatment  was  discontinued  because  it  appeared 
that  healing  was  complete.  I  made  the  following  find:  Hand  is 
slightly  subluxated,  wrist-joint  is  not  swollen  any  more.  Fistulae  and 
ulcers  have  firmly  cicatrized'.  The  \wrist-joint,  in  spite  of  the  sub- 
luxation,  fully  permits  all  motions.  The  child  uses  its  left  hand 
just  as  well  as  the  right  one.  It  has  also  used  it  during  the  treat- 
ment as  well  as  it  could.  The  Roentgen  picture  taken  July  12,  1901, 
shows  weak  and  blurred  outlines  of  the  carpal  bones;  that  taken 
January  7,  1902,  shows  plainer  outlines.  All  other  bones  of  the 
hand  and  forearm  were  very  much  atrophied.  The  Roentgen  pic- 
ture taken  August  23,  1902,  shows  sharp  outlines  of  bones,  but  such 
considerable  destruction  in  the  carpal  and  metacarpal  bones  that  one 
must  wonder  at  the  good  function. 

With  this  method  of  treatment  edema  was  found  only 
at  first.  Its  disappearance  was  caused  bv  high  posture  of 
the  limb  during  the  intermissions. 

Since  applying  the  remedy  in  this  form  I  have  scarcely 
seen  cold  abscesses ;  at  least,  they  did  not  appear  any 
oftener  than  usually  observed  in  tuberculous  patients  ;  the 
results  were  quite  satisfactory.  However,  even  this 
method  of  application  is  too  complicated  for  general  prac- 
tical use  and  we. now  almost  exclusively  make  use  of  a 
method  established  by  Tilmann  in  the  Greifswald  Surgi- 
cal Polyclinic  and  with  which  he  obtained  excellent  re- 
sults in  the  out-door  treatment  of  tuberculous  joints.  He 
applies  stasis  only  one  hour  daily  in  a  manner  described 
in  Chapter  VII  (see  Fig.  6).  For  this  time  it  is  per- 
missible to  allow  the  hyperemia  to  strongly  affect  the 
limb,  but  the  bandage  must  not  be  applied  tight  enough 
to  cause  pain  or  paresthesia  in  the  treated  extremity. 
I  also  do  not  consider  the  appearance  of  the  above- 
described  vermilion  spots  useful.  However,  the  hyper- 
emia must  be  intense.  Demonstrable  edema  does  not  oc- 
cur in  the  short  period  of  one  hour  but  a  decided  swell- 
ing of  the  treated  part  of  the  limb.  The  parts  situated 
peripherically  from  the  affected  place  are  not  bandaged, 
and  thus  the  method  is  still  more  simplified  when  com- 
pared with  the  previous  one.  It  is  also  not  necessary 
that  the  stasis  bandage  be  applied  closely  above  the  af- 
fected joint  but  can  safely  be  put,  for  instance,  in  tuber- 
culosis of  the  wrist  or  ankle-joint,  around  the  upper  arm 


TREATMENT  OF  TUBERCULOSIS  185 

or  thigh  whenever  there  seems  to  exist  a  reason  that  this 
is  desirable. 

With  this  form  of  application  of  stasis  hyperemia  I  be- 
lieve the  reproach,  which  could  be  made  previously,  that 
it  is  difficult  and  in  the  hands  of  the  inexperienced  dan- 
gerous, is  conclusively  unjustified.  I  recommend  it, 
therefore,  for  use  by  the  general  practitioner,  especially 
since  this  short  application  is  followed  by  as  good  results 
as  those  of  longer  application.  To  prove  this  I  cite  the 
following  case : 

A  laborer,  twenty-three  years  old,  suffered  for  four'  years  from 
a  tuberculous  inflammation  of  the  right  foot.  Three  weeks  prior 
to  admission  he  was  confined  to  bed,  because  the  right  foot  caused 
severe  pain  whenever  he  tried  to  press  on  it.  Pain  also  occurred 
spontaneously,  so  that  the  patient  frequently  could  not  sleep  at  night. 

On  admission,  April  1,  1902,  the  right  ankle-joint  was  irregularly 
swollen.  Its  circumference  exceeded  that  of  the  other  joint  by  9cm. 
Motions  were  very  painful  and  possible  only  to  a  slight  extent. 
The  patient  could  walk  lamely  and  with  pain  by  the  aid  of  two 
canes.  The  joint  was  everywhere  sensitive  to  pressure. 

The  region  of  Chopart's  joint  is  swollen,  the  talo-navicular  joint 
very  sensitive  even  to  the  least  pressure.  In  front  of  the  external 
malleolus  is  found  a  soft,  fluctuating  swelling. 

The  Roentgen  picture  shows  enormous  destruction  of  the  talus, 
great  destruction  on  the  ankle-joint  surface,  periosteal  granulations 
in  the  calcaneus,  and  pronounced  atrophy  of  all  bones  of  the  foot 
and  leg. 

April  8,  1902,  stasis  hyperemia  was  applied  one  hour  and_this 
treatment  repeated  daily,  which  rapidly  relieved  the  pain  and  in- 
creased the  mobility  of  the  affected  foot.  The  soft  swelling  in  front 
of  the  external  malleolus  developed  into  a  cold  abscess,  which 
was  incised  on  April  22nd  under  Schleich's  infiltration  anesthesia. 
About  a  teaspoonful  of  pus  was  evacuated.  Stasis  hyperemia  was 
continued. 

June  10th  at  the  opening  of  the  fistula  the  point  of  a  sequestrum 
was  noticed ;  this  was  extracted.  It  had  the  size  of  half  a  white 
bean  and  was  strongly  carious.  June  llth  and  17th  small  sequestra 
were  expelled. 

August  5th  the  affected  joints  everywhere  became  tough  and 
hard.  Bright  red  strong  granulations  sprang  from  the  fistula  in 
front  of  the  malleolus,  but  little  pus  being  excreted  from  it.  There 
was  no  pain  on  pressure  or  motion.  As  other  sequestra  were  sus- 
pected, the  fistula  was  divided  to  the  extent  of  3  cm.  under  Schleich's 
infiltration  anesthesia  and  a  sequestrum  as  big  as  a  pea  and  four 
smaller  ones  were  removed  with  a  sharp  spoon.  The  wound  was 
covered  with  aseptic  gauze.  The  first  dressing  remained  in  situ  eight 
days.  August  14th  another  small  sequestrum  was  expelled  from  the 
fistula.  August  22nd  the  fistula  was  firmly  closed.  The  patient  is 
able  to  walk  without  cane  or  pain;  mobility  of  the  ankle-joint  is 


186  TREATMENT  OF  TUBERCULOSIS 

present    a   moderate    degree.    The    circumference    has    diminished 
5  cm. 

As  long  as  the  fistulas  remained  open  the  patient  was  ordered 
confined  to  bed,  but  had  to  walk  daily  about  fifty  paces  as  soon  as 
the  pain  had  disappeared. 

I  apply  but  rarely  in  addition  to  this  form  of  stasis 
hyperemia  other  conservative  measures.  I  have  almost 
entirely  abandoned  the  combination  of  stasis  hyperemia 
with  iodoform  treatment.  Even  the  cold  abscesses  are 
not  treated  any  more  by  aspiration  and  subsequent  filling 
with  iodoform-glycerin.  If  they  have  existed  previously 
they  are  opened  by  a  small  incision  and  the  pus  evacu- 
ated. One  to  three  days  afterward  stasis  hyperemia  is 
instituted.  If  abscesses  develop  during  the  application 
of  this  remedy  it  is  stopped  for  a  few  days ;  they  are  also 
incised.  The  fistulae  thus  created  heal  slowly  while 
stasis  is  continued.  Occasionally  the  small  wound  heals 
rapidly  under  the  influence  of  the  hyperemia  by  means  of 
a  blood  coagulum.  If  pus  reaccumulates  the  latter  must 
be  removed. 

Large  cold  abscesses  I  occasionally  incise,  curette,  fill 
them  with  iodoform-glycerin  after  the  method  of  Billroth 
and  close  the  wound  by  suture.  Stasis  hyperemia  for  the 
joint  tuberculosis  is  instituted  only  after  the  wounds  have 
healed. 

Of  late  I  make  no  difference  between  open  and  closed 
tuberculosis  and  treat  one  the  same  as  the  other.  If  we 
have  to  deal  with  fistulous  or  ulcerated  joints  the  dressing 
is  removed  during  the  hourly  application  of  the  stasis  and 
the  limb  placed  on  cotton,  which  catches  the  excreted 
serum,  -pus  and  occasionally  blood  which  appear  during 
the  stasis.  The  affected  limb  hangs  or  lies  free,  or 
is  loosely  covered  with  cotton. 

Fistulae  frequently  close  under  stasis  hyperemia.  If 
they  remain  open  though  the  diseased  joint  has  improved, 
the  fault  is  usually  due  to  hidden  sequestra.  In  two 
cases  I  observed  how  the  sequestra  were  expelled  from 
the  fistula  under  this  treatment ;  in  other  cases  they  must 
be  removed.  The  above-cited  cases  offer  the  best  ex- 
ample for  this. 

In  tuberculous  ulcers  the  beginning  of  improvement  is 
first  noticed  on  the  fresher  color  of  the  granulation. 


TREATMENT  OF  TUBERCULOSIS  187 

Special  proof  that  healing  is  making  progress  is  had  when 
the  margins  of  the  skin  of  the  tuberculous  ulcers,  which 
-  almost  always  are  undermined,  heal  firmly  to  the  base 
and  epithelisation  commences  at  the  margins.  Im- 
mobilizing dressings  are  used  in  a  few  isolated  cases  and, 
in  fact,  are  not  necessary  because  any  pain  in  the  ma- 
jority of  cases  is  quickly  relieved  by  the  stasis  hyperemia 
or  at  least  so  much  improved  that  immobilization  be- 
comes unnecessary.  I  even  instituted  careful  passive  and 
active  motions  as  soon  and  as  much  as  the  pain  permits 
this. 

I  also  do  not  hastily  resort  to  extension.  Contractions 
for  which  it  is  indicated,  as  a  rule,  are  seen  to  improve 
after  a  few  weeks,  especially  if  the  limb  is  daily  sup- 
jected  to  careful  active  and  passive  motions.  If  the  in- 
tense forms  of  contractions  are  not  dissolved  by  the 
stasis  hyperemia  any  kind  of  an  extension  dressing  for 
the  purpose  of  straightening  of  the  limb  can  be  utilized, 
which,  however,  should  be  removed  when  the  contrac- 
tion has  been  overcome.  The  extension,  therefore,  is 
solely  an  orthopedic  remedy. 

Special  mention  is  merited  by  the  flexion  contraction 
of  the  knee-joint,  which  frequently  occurs  in  spite  of  heal- 
ing or  improvement  of  the  tuberculosis  of  the  joint.  It  is 
noteworthy  that  it  is  not  infrequently  the  apparently  mild 
form  of  cases  which  show  this  phenomenon,  while  grave 
cases  become  perfectly  mobile.  In  these  contractions  im-< 
mobolizing  bandages  or  apparatus  which  effect  the  posi- 
tion of  extension  should  be  employed. 

As  soon  as  the  pain  has  disappeared  I  have  no  scruples 
in  permitting  the  limited  use  of  the  tuberculous  extremi- 
ties during  treatment.  I  permit  people  with  affected 
shoulder,  elbow  and  wrist-joints  to  use  the  arm  for 
smaller  work  required  in  daily  life.  People  with  diseased 
knee-joints,  provided  that  they  have  so  far  improved  that 
walking  is  possible  without  producing  discomfort  and 
that  there  are  not  present  large  tuberculous  ulcers  or 
excreting  fistulae,  are  permitted  to  walk.  I  am  more 
careful  in  affections  of  the  ankle-joint  because  the  weight 
of  t-he  body  is  apt  to  produce  flat  feet.  Here  the  patient 
is  enabled  to  walk  while  out  of  bed  by  carrying  a  plaster 
of  paris  cast,  made  from  two  halves  so  that  they  can  be 


188  TREATMENT  OF  TUBERCULOSIS 

easily  removed.  As  soon  as  the  patient  goes  to  bed,  the 
bandage  is  removed  so  that  motions  of  the  diseased  joint 
can  be  executed.  In  cases  in  which  the  foot  inclines  to 
tip-foot  position  or  is  still  very  painful,  it  must  be  pro- 
tected against  the  bed-cover  by  a  hoop.  Naturally  the 
use  of  the  limb  is  permitted  only  to  that  extent  that  no,  or 
at  least  very  slight,  inconvenience  arises  therefrom,  and 
that  this  does  not  increase  by  it. 

This  treatment  has  the  advantage  that  it  leads  to  func- 
tionally useful  joints,  for  it  is  a  poor  result  of  a  tedious, 
conservative  treatment  of  a  tuberculous  joint  if  it  ter- 
minates into  a  stiffness  of  the  diseased  joint.  For  this 
reason  I  have  from  the  very  beginning  of  my  experi- 
ments as  much  as  possible  declined  to  immobilize  the 
tuberculous  joints,  and  thus,  as  far  as  usefulness  of  the 
joints  is  concerned,  have  obtained  a  number  of  brilliant 
and  lasting  results  of  which  I  will  cite  here  a  few  ex- 
amples : 

1.  An  eight-year-old  boy  two  years  previous  to  his  admission  in 
the  surgical  clinic  at  Kiel  became  affected  with  tuberculosis  of  the 
knee-joint,  which  had  been  treated  with  sea  baths  and  leather  splints 
with  but  temporary  success.     On  admission  was  found  a  tumor  albus 
of  the  left  knee-joint  and  subluxation  of  the  leg  posteriorly  and 
slight  contraction  in  flexion.     Pain  was  slight  but  the  patient  was 
unable  to  walk.     I  first  treated  the  diseased  knee  with   iodoform 
injections  without  any  success  and  from  November  29,  1891,  to  Jan- 
uary 25,  1892,  also  without  success. 

From  May  14.  to  June  27,  1892,  prolonged  stasis  hyperemia  was 
applied.  Then  this  agent  was  applied  during  the  night  only  and 
finally  only  one  hour  daily.  After  this  the  affection  improved. 
Now  after  ten  years  the  young  man,  who  has  chosen  a  business 
career,  informs  me  that  both  knees  are  equally  mobile,  large  and 
strong,  and  that  he  can  stand  and  walk  all  day  long,  laming  with  the 
left  leg  a  little  only  after  extended  marching  tours. 

2.  I  treated,  in  1892,  in  Kiel,  a  seventeen-year-old  tailor  appren- 
tice, who  for  two  years  had  suffered  from  tuberculosis  of  the  right 
wrist-joint.     I  found  a  fusiform  swelling  of  the  right  wrist-joint. 
Rotation   and   extension  were  entirely   suspended,   flexion   possible 
only  in  a  small  degree.     On  each  attempt  at  motion  great  pain  was 
produced.     The  hand  was  useless. 

Stasis  hyperemia  was  applied  continually  from  June  15  to  August 
25,  1892,  then  up  to  October  24th  nights  only.  I  can  not  now  estab- 
lish how  long  after  that  he  used  the  remedy  by  the  hour. 

The  father  of  the  patient  now  advises  me  that  the  right  hand 
remained  somewhat  smaller  and  the  right  arm  somewhat  thinner 
than  the  left,  the  disease  itself,  however,  has  so  healed  that  his 
son,  who  has  abandoned  tailoring  and  has  become  a  stable-man, 


TREATMENT  OF  TUBERCULOSIS  189 

can  do  the  hardest  work  with  the  cured  hand  without  injury;  the 
hand  is  usable  to  the  fullest  extent. 

3.  An  eleven-year-old  girl  was  afflicted  with  tuberculosis  of  the 
elbow-joint.  The  right  elbow-} oint  was  fusiformly  swollen,  and 
was  fixed  in  a  right  angle.  Motions  were  almost  suspended.  The 
joint  was  sensitive  to  pressure.  Stasis  hyperemia  (prolonged)  was 
applied  from  March  15  to  April  26,  1892,  and  nightly  from  this 
date  to  June  26,  1892.  In  the  last  two  months  the  joint  was  care- 
fully massaged,  and  passively  moved  during  the  day.  June  26th  the 
child  was  discharged.  The  stasis  hyperemia  was  continued  at  home 
during  the  night  and  later  one  hour  daily. 

The  girl  is  now  grown.  Her  joint  is  movable  to  the  greatest 
extent,  and  can  be  used  for  work.  Only  after  severe  exertion  even 
now  appears  a  sensation  of  lameness  in  the  right  arm,  which  soon 
disappears  after  a  short  application  of  stasis  hyperemia. 

The  above-described  method  of  treatment,  in  my 
opinion,  is  not  only  the  best  but  it  also  has  the  great 
advantage  of  being  the  simplest  and  cheapest,  especially 
since  this  treatment  can  be  carried  out  at  home,  in  the 
office  or  the  dispensary,  as  has  been  shown  by  Tilmann, 
at  least  as  far  as  the  upper  extremities  and  the  incipient 
and  milder  forms  of  the  lower  extremities  are  concerned. 
The  physician  can  make  an  appointment  with  his  patients 
at  his  office,  apply  the  stasis  hyperemia,  and  have  them 
remain  in  his  waiting-room  while  he  personally  convinces 
himself  about  the  correct  position  of  the  bandage.*  As 
the  conservative  treatment  of  tuberculosis  is  so  tedious 
that  it  can  hardly  be  carried  out  to  the  end  in  the  hos- 
pital, I  am  in  the  habit  of  permitting  the  patients  them- 
selves to  apply  the  bandage  to  the  lower  extremities,  and 
thus  daily  convince  myself  that  they  have  executed  it 
correctly.  In  such  cases  out-door  treatment  is  possible 
very  soon.  A  second  person  must  apply  the  bandage 
to  the  arm.  The  patient  himself  states  whether  it  is  too 
loose  or  too  tight.  Skill  is  not  necessary  for  this. 

There  are  no  dangers  connected  with  stasis  hyperemia 
applied  only  one  hour  daily ;  it  leads  neither  to  cold  ab- 
scesses nor  to  excessive  granulations  nor  to  acute  inflam- 
mations. If  abscesses  develop  they  are  incised. 

Frequently  the  objective  changes  in  the  joint  do  not 
keep  pace  with  the  improvement  of  function  and  the 

*This  is  especially  important  in  the  beginning  and  with 
patients  of  limited  intelligence.  One  frequently  makes  the  obser- 
vation that  an  apparently  well-placed  and  properly  fitting  bandage 
alter  one-quarter  of  an  hour  is  either  too  loose  or  too  firm. 


190  TREATMENT  OF  TUBERCULOSIS 

decrease  of  pain.  Especially  the  swelling  is  occasionally 
present  in  its  entire  circumference,  while  the  limbs  are 
already  used  without  inconvenience,  differentiating  from 
the  original  swelling  only  by  a  greater  hardness.  Return 
to  the  normal  form  of  the  joint,  as  a  rule,  takes  place 
gradually. 

I  also  have  seen  cases  of  tuberculosis  which  improved 
with  incredible  rapidity  under  stasis  hyperemia  so  that 
they  soon  entirely  lost  the  character  of  a  tuberculous 
affection.  These  cases  are  so  striking  that  I  always  seri- 
ously considered  whether  I  could  count  them  as  tuber- 
culous and  assumed  that  we  may  have  to  deal  with  a 
diagnostic  error  in  so  far  as  an  osteomyelitic,  gonorrheal 
or  otherwise  affected  joint  for  once  took  a  chronic  course 
and  erroneously  being  accepted  as  tuberculosis.  Never- 
theless, I  have  seen  four  to  five  of  such  cases  in  which 
not  the  least  doubt  as  to  the  correctness  of  the  diagnosis 
could  exist. 

All  these  forms  of  tuberculosis  which  rapidly  change 
their  character  under  stasis  hyperemia  without  exception 
characterize  themselves  by  the  appearance  of  an  intense 
reaction  beneath  the  stasis  bandage,  frequently  even  at 
slight  constriction.  The  diseased  joint  becomes  bright 
red  in  color  and  hot  to  the  feel.  Occasionally  blisters  or 
acute  eczemata  appear,  so  that  one  who  would  see  the 
limb  but  not  the  bandage  could  assume  it  to  suffer  from 
an  intense,  acute  inflammation.  After  a  few  weeks  all 
remedies  can  be  dispensed  with,  the  tuberculosis  heals 
itself  with  formation  of  stone-hard  connective  tissue  in 
the  diseased  joint.  It  is  to  be  regretted  that  these  cases 
are  extremely  rare. 

We  yet  have  to  draw  the  limits  within  which  the  stasis 
hyperemia  is  indicated  for  tuberculous  joints.  It  is  aban- 
doned and  replaced  by  other  conservative  measures  when 
it  does  not  produce  an  improvement  of  the  affection.  It 
is,  furthermore,  not  to  be  recommended,  as,  in  fact,  all 
conservative  remedies,  in  such  cases  where  the  position 
of  the  limb  is  so  faulty  and  must  remain  faulty  that  even 
at  best  the  result  of  conservative  treatment  is  worse  than 
that  of  resection,  to  which  procedure  we  have  to  resort 
after  the  improvement  of  the  disease. 

In  very  large  tuberculous  abscesses  and  especially  in 


TREATMENT  OF  TUBERCULOSIS  191 

hydrops  tuberculosis,  treatment  with  iodoform  is  superior 
to  stasis  hyperemia,  and  is  therefore  always  instituted  by 
us.  On  the  other  hand,  in  both  cases  after  the  disappear- 
ance of  the  pus  or  watery  effusion  stasis  hyperemia  is 
frequently  very  useful  as  after  treatment. 

I  must  also  devote  a  few  words  to  the  so-called  ampu- 
tation cases  in  tuberculosis  of  joints.  That  in  fully  de- 
veloped cases  of  pulmonary  consumption  and  in  incipient 
amyloid  a  gravely  affected  tuberculous  joint  is  to  be 
amputated  is  so  self-evidenfthat  there  is  no  need  wasting 
words  on  it.  Even  otherwise  cases  may  occur  where  one 
would  be  guilty  of  omission  if  in  consideration  of  the 
general  condition  amputation  were  not  performed. 
These  aside,  I  never  know  in  the  beginning  any  case 
of  amputation  but  treat  them  all  at  first  conservatively 
as  an  experiment.  For  I  have  seen  the  gravest  cases 
heal  under  conservative  methods,  especially  under  stasis 
hyperemia.  The  case  of  the  twenty-three-year-old 
laborer  described  in  the  beginning  of  this  chapter  is  such 
a  case.  A  well-known  and  experienced  colleague  whom 
I  showed  the  patient  in  the  beginning  of  the  treatment 
expressed  the  opinion  that  it  was  a  "primary  amputation 
case,"  where  one  had  best  not  tarry  with  conservative 
treatment  nor  witrf  resection.  Now  the  man  is  using  his 
legs.  On  the  other  hand,  we  have  incipient  forms  of 
tuberculosis  apparently  having  the  best  change  which,  in 
spite  of  immediately  instituted,  rational,  conservative 
treatment,  proceed  unimpeded  and  finally  have  to  be 
subjected  to  the  surgeon's  knife. 

Finally,  I  should  mention  the  observations  which 
others  have  made  with  stasis  hyperemia  produced  with 
the  rubber  bandage.  But  the  literature  on  the  subject, 
though  my  first  contribution  on  this  method  was  made 
eleven  years  ago,  is  so  meager  that  it  is  not  worth  while 
to  examine  it.  Results  were  good  and  bad,  the  latter,  as 
I  know  from  oral  inquiries,  more  than  the  meager  litera- 
ture seems  to  indicate.  In  the  majority  of  places  the 
method  has  been  decried  as  dangerous,  uncertain,  or 
ineffective.  However,  this  does  not  discourage  me.  I 
know  very  well  that  it  is  not  only  dishonest  but  also 
stupid  to  attempt  to  hold  a  post  recognized  as  doomed. 
But  I  do  not  yield  here  one  step,  on  the  contrary,  make 


192  TREATMENT  OF  TUBERCULOSIS 

one  in  a  forward  direction  and  assert  that  the  largest 
part  of  the  failures  is  to  be  ascribed  to  faulty  technic, 
from  which  reproach  I  can  not  even  free  myself.  And 
while  formerly  I  claimed  for  stasis  hyperemia  that  it  was 
a  good  method  of  treatment  of  tuberculosis  of  joints, 
which  claims  a  prominent  place  alongside  the  other 
methods,  I  now  declare  it  the  best  conservative  agent  at 
our  command,  which  with  the  least  dangers  simply  and 
cheaply  achieves  results,  especially  as  far  as  function  of 
the  diseased  joints  is  concerned,  with  which  none  of  the 
others  can  be  measured  even  approximately.  It  must  be 
added  that  at  the  same  time  it  is  the  most  agreeable  of 
them  all  because  it  takes  away  the  pain  from  the  patient 
without  causing  him  any  new  ones,  leaving  him  most 
perfectly  the  use  of  his  limb. 

With  this  I  do  not  mean  to  say  that  the  mutilating 
operations  have  been  done  away  with ;  for  even  this  rem- 
edy frequently  leaves  us  in  the  lurch,  it  is  by  no  means  in- 
fallible, especially  as  it  is  a  pronounced  individual  rem- 
edy, for  the  main  question  always  is  centered  in  the  kind 
of  blood  the  patient  places  at  our  disposal  against  the 
disease.  But  I  hope  that  with  the  progressive  experi- 
ence in  this  domain,  with  the  better  development  of 
technic  for  each  individual  case,  results  will  be  still  more 
favorable  and  operations  pushed  to  the  background. 

More,  recently  we  have  again  commenced  to  treat  open 
and  closed  tuberculosis  of  joints  with  the  suction  appara- 
tus, having  made  but  a  few  experiments  years  ago.  This 
was  mostly  used  twenty  minutes,  rarely  one  half  hour 
or  longer  daily. 

If  a  tuberculous  joint  is  placed  into  the  apparatus  and 
the  air  within  thinned,  enormous  hyperemia  and  swelling 
of  the  affected  part  occur.  Occasionally  this  is  not  so 
pronounced  in  the  first  few  days,  but  after  the  apparatus 
has  been  used  two  to  four  times  it  appears  in  an  intense 
form  with  great  regularity.  From  the  fistulae  and  ulcers 
bloody  colored  serum  and  pus  flow  out,  while  granulating 
masses  protrude  as  if  they  were  sucked  out  from  the 
depth.  In  the  beginning  hemorrhages  frequently  take 
place  from  fistulse  and  ulcers,  but  after  repeated  use  of 
the  apparatus  the  granulations  become  more  capable  of 
resistance  and  do  not  bleed  any  more.  Daily  use  of  the 


TREATMENT  OF  TUBERCULOSIS  193 

apparatus  produces  edema,  which  may  reach  the  highest 
degrees  and  become  chronic,  this  even  though  the  appara- 
tus be  used  only  every  other  day. 

The  effects  of  the  apparatus  on  the  course  of  tuber- 
culosis, if  used  daily,  were  variable.  In  some  cases  it 
produced  rapid  and  striking  improvement,  in  others  just 
as  rapidly  aggravation,  on  the  whole  similar  in  character 
to  that  experienced  with  excessive  stasis  hyperemia,  viz. : 
Cold  abscesses,  breaking  through  and  changing  into  ul- 
cers, granulating  masses  and  development  of  rodent  ulcer 
with  undermined,  thin  margin  of  the  skin,  etc.,  with  the 
only  difference  that  the  entire  process  occurred  more 
rapidly  correspondingly  to  the  greater  and  more  ener- 
getic effectiveness  of  the  apparatus.  On  the  other  hand, 
we  had  the  best  results  with  this  agent.  I  will  cite 
examples  for  both : 

A  woman,  fifty-one  years  old,  during  an  attack  of  vertigo  in 
February,  1901,  fell  to  the  floor ;  a  few  days  later  pain  appeared 
in  the  knee-joint,  which  became  considerably  worse  and  at  last 
so  intense  that  the  patient  could  limp  only  while  walking  with 
great  pain,  which  latter  awakened  her  even  from  sleep.  Admitted 
February  15,  1902. 

The  left  knee-joint  is  fusiformly  swollen  and  is  2l/$  en1-  larger 
in  circumference  than  the  right;  it  is  fixed  in  flexion  contraction, 
can  not  be  extended,  and  can  actively  be  bent  to  less  than  a 
right  angle.  On  flexing  the  joint,  pseudo-fluctuating  swellings  ap- 
pear laterally  and  below  the  patella. 

Suction  apparatus  was  used  twenty  minutes  daily,  from  Feb- 
ruary 20th  to  April  8th.  A  decided  hyperemia  appeared  only  after 
the  third  application  and  thereafter  regularly.  Edema  did  not  form. 

March  14th  the  patient  had  lost  her  pain,  walked  without  laming, 
free  from  pain,  felt  perfectly  healthy,  and  could  even  run.  April  9th 
she  was  discharged,  with  the  following  result:  The  knee  can  be 
fully  extended  and  actively  bent  to  an  angle  of  70  degrees.  The  cir- 
cumference of  the  left  knee  at  its  largest  point  measures  1  cm. 
more  than  that  of  the  right.  The  patient  can  use  her  knees  all  day 
long  without  any  inconvenience. 

The  next  case  is  an  example  of  a  cure  of  very  grave 
and  far  progressed  tuberculosis  of  the  joint  by  hyperemia 
with  the  suction  apparatus: 

A  boy,  aged  thirteen,  became  affected,  in  August,  1900,  with 
tuberculosis  of  the  left  elbow-joint.  He  was  admitted  to  the  sur- 
gical clinic  (Greifswald)  June  12,  1901.  There  was  a  fusiform 
swelling  of  the  left  elbow-joint,  which  had  led  to  cold  abscesses. 
The  Roentgen  picture  showed  an  apparent  sequestrum  in  the 

13 


194  TREATMENT  OF   TUBERCULOSIS 

olecranon.  The  joint  was  fixed  at  an  angle  of  105  degrees.  Motions 
were  impossible  actively  and  but  slight  passively. 

As  we  had  here  to  deal  with  tuberculosis  with  abscesses,  these 
were  incised,  curetted  and  sutured,  after  the  method  of  Billroth, 
after  being  filled  with  iodoform-glycerin ;  the  suspected  sequestrum 
in  the  olecranon  was  not  found.  Healing  took  place  almost  by  first 
intention  and  the  patient  was  sent  back  to  his  family  physician  for 
treatment  July  12,  1901. 

The  boy  was  readmitted  February  21,  1902,  with  a  severe  tuber- 
culosis of  the  elbow-joint.  The  joint  was  irregularly  swollen  and 
surrounded  by  a  chain  of  large  ulcers,  which  were  covered  with 
spongy,  gray  granulations,  whose  skin  margins  were  undermined 
and  from  which  fistulae  led  into  the  depth.  The  largest  of  these 
ulcers  was  as  big  as  a  dime.  Ulcers  and  fistulae  suppurated  con- 
siderably. The  probe  met  rough  bone.  The  skin  was  so  exten- 
sively undermined  that  the  probe  pushed  into  a  fistula  reappeared  at 
the  opening  of  another  7  cm.  distant.  The  elbow  was  very  sensitive 
to  pressure,  the  left  upper  arm  was  decidedly  atrophic. 

The  patient  was  treated  with  the  suction  apparatus  twenty  min- 
utes daily  since  February  25th.  The  region  of  the  joint  became 
dark  blue;  bloody  serum,  pus,  blood  and  spongy  granulation  masses 
were  drawn  from  the  fistulae.  For  hours  after  the  application  of 
the  apparatus  the  region  of  the  affected  joint  was  hot  to  the  feel. 
After  fourteen  days  "the  excretion  from  fistulae  and  ulcers  greatly 
diminished,  the  granulations  began  to  look  dark  red,  the  undermined 
skin  began  to  heal  to  its  basis.  Fourteen  days  later  it  could  be 
noticed  that  the  previously  soft  swelling  became  hard.  May  1st 
it  was  established  that  the  fistulae  scarcely  secreted,  the  skin  had 
healed  everywhere  and  that  the  ulcers  were  covered  with  a  crust 
which  was  left  undisturbed.  In  May  an  intermission  of  two  weeks 
was  ordered,  after  which  treatment  with  the  suction  apparatus  was 
resumed  and  now  administered  every  other  day.  The  patient  was 
discharged  August  1,  1902,  with  the  following  result :  All  ulcers  and 
fistulae  have  healed  and  are  covered  with  skin;  the  joint  looks 
smooth  and  has  lost  the  form  of  a  spindle ;  it  feels  hard  all  around. 
Mobility  has  not  increased.  The  patient  previous  to  his  discharge 
has  been  taught  the  use  of  the  stasis  bandage,  which  he  is  instructed 
to  use  one  hour  daily  for  one  or  more  months,  when  he  is  to  present 
himself  at  the  clinic. 

The  Roentgen  picture  offered  some  interesting  points.  The  one 
taken  at  admission  of  the  patient  showed  the  ends  of  the  joint  con- 
fluent and  undeterminable.  The  bones  were  very  atrophic.  With 
progressive  improvement  the  bones  became  plainer,  and  on  discharge 
the  bones  became  sharply  defined  and  showed  a  darker  shadow  in 
the  region  where  the  disease  had  its  seat  than  that  of  the  healthy, 
distant  parts.  To  judge  from  the  picture  there  exists  a  bony  anky- 
losis  of  the  articular  ends;  in  the  soft  parts  cordlike  dark  shadows, 
which  probably  represent  tough  connective  tissue  strands,  which  have 
developed  from  the  granulations  and  which  cause  the  joint  to  appear 
so  hard  to  the  palpating  finger. 

In  contradistinction  to  these  successes,  which  I  could 


TREATMENT  OF  TUBERCULOSIS  195 

multiply  considerably,  we  have  observed  the  contrary  in 
tuberculosis  of  the  joints  under  the  influence  of  the  suc- 
tion apparatus.  The  two  worst  cases  I  let  follow : 

1.  A  cabinet-maker,  fifty-three  years  old,  states  that  he  took  sick 
February  23,   1901,  subsequent  to  a  sprain  of  the  right  wrist-joint. 
This   became   painful   and   swollen.     The   symptoms   became   aggra- 
vated, for  which  reason  patient  was  admitted  November  22,  1901. 

He  suffered  from  extensive,  double-sided  pulmonary  tuberculosis. 
The  right  wrist-joint  had  a  larger  circumference  of  3l/2  cm.  than 
that  of  the  left.  It  was  almost  entirely  stiff,  in  fact,  so  much  that 
the  finger-tips  at  the  attempt  to  make  a. fist  remained  I1/?  cm.  disant 
from  the  palm.  Rotation,  too,  was  considerably  limited. 

The  affected  limb  was  treated  one-half  hour  twice  daily  with 
the  suction  apparatus  since  November  24th.  Decided  hyperemia 
appeared  and  after  a  few  applications  also  chronic  edema.  January 
'23,  1902,  I  found,  after  an  improvement  in  the  mobility  of  the 
finger  and  wrist-joints,  a  cold  abscess  on  the  ulnar  side  of  the 
hand,  which  was  aspirated  without  injection  of  iodoform.  Treat- 
ment with  the  suction  apparatus  was  suspended  for  a  few  days 
and  then  resumed.  Since  February  14th  the  apparatus  is  used 
only  twenty  minutes  every  other  day.  February  20th  the  abscess 
perforated  spontaneously,  and  as  there  appeared  to  exist  pus  reten- 
tion, it  was  incised.  A  mixed  infection  occurred  with  high  fever, 
so  that  April  23d  resection  of  the  wrist-joint  had  to  be  performed, 
and  owing  to  progressive  suppuration,  the  arm  was  amputated 
May  27th. 

2.  A  boy,  three  years  old,  strongly  scrophttlous,  suffered  from 
open  grave  tuberculosis  of  the  right  wrist-joint.     He  received  daily 
treatments  of  twenty  minutes'  duration  with  hyperemia  by  the  suc- 
tion apparatus.     First  treatment  was  given  March  25,  1902.     March 
26th   developed   an   acute   inflammation   of  the   affected  joint   with 
reddening   of  the   skin   up   to  the  upper   arm,   which   compelled  us 
to   suspend   the   treatment.     The   inflammation   disappeared   after   a 
few  days  but  meanwhile  the  tuberculosis  of  the  wrist-joint  made 
considerable  progress.     The  trouble  was  aggravated  by  the  appear- 
ance of  several  new  ulcers  with  strong  granulations  and  undermined 
margins.     Since  June  2oth  stasis  hyperemia  by  bandage  was  insti- 
tuted which  produced  a  slow  but  decided  improvement. 

Thus  in  the  treatment  with  the  suction  apparatus  we 
have  had  alongside  of  successes  the  same  failures  we 
have  seen  before  in  prolonged  and  intense  stasis  by  band- 
age and  have  drawn  the  conclusion  that  we  have  used 
the  suction  apparatus  too  long  and  too  forcibly.  After 
these  preliminary  experiments  we  have  reduced  its  ap- 
plication, so  that  it  does  not  produce  chronic  edema. 
For  this  reason  I  never  use  it  daily  but,  depending  on  the 
reaction  it  produces,  for  twenty  minutes  every  second  to 


196  TREATMENT  OF  TUBERCULOSIS 

fourth  day.  We  take  care  that  it  is  not  used  again  until 
all  edema  has  disappeared.  Since  this  is  observed  we 
have  not  seen  those  failures  but  our  experience  with  this 
method  is  so  limited  that  we  can  not  pass  an  opinion  on 
its  merits  as  a  therapeutic  agent  for  tuberculosis  of  the 
joints.  I  recommend  that  for  the  present  the  general 
practitioner  use  hyperemia  produced  by  the  application 
of  the  bandage,  and^advise  against  the  use  of  the  suction 
apparatus  until  further  experience  concerning  the  caution 
with  which  it  has  to  be  applied  and  its  effect  can  be 
acquired. 

TREATMENT  OF  OTHER  FORMS  OF  TUBERCULOSIS 

Besides  tuberculosis  of  the  joints,  it  was  that  of  the 
testes  which  I  have  treated  most  frequently  by  means 
of  stasis  hyperemia,  which  is  applied  in  the  following 
manner : 

If  both  testes  are  diseased  they  are  firmly  drawn  down- 
wards and  a  soft  piece  of  rubber  tubing  padded  with  cot- 
ton is  placed  around  the  basis  of  the  scrotum  and  so 
firmly  drawn  that  it  produces  stasis  hyperemia ;  the  ends 
of  the  rubber  are  closed  with  a  pair  of  forceps.  If  only 
one  testis  is  diseased,  it  is  drawn  downwards,  while  the 
healthy  one  is  pushed  upwards.  The  rubber  constrictor 
is  applied  in  the  same  manner.  The  testes  are  placed  in 
a  spacious  suspensory.  The  constrictor,  since  the  place 
of  constriction  can  not  be  changed,  is  permitted  to  remain 
one  hour  only. 

One  easily  succeeds,  in  this  manner  in  producing  an  in- 
tense stasis  hyperemia  in  the  testicles.  I  have  made 
good  use  of  it  in  ulcerating  and  fistulous  cases,  and  have 
observed  how  large  ulcers  have  healed.  The  agent 
proved  less  successful  in  the  tuberculous  indurations  of 
the  epididymis  as  they  are  found  in  the  beginning  of  the 
disease. 

In  spite  of  good  results,  I  have  almost  entirely  dis- 
carded the  stasis  hyperemia  in  tuberculosis  of  the  testes, 
for  one  gets  but  rarely  a  case  for  treatment  where  the 
tuberculosis  is  limited  to  the  epididymis  or  to  it  and  the 
testes.  As  a  rule,  the  vas  deferens  or  even  deeper  parts 
have  already  been  attacked,  which  are  beyond  reach  of 
the  influence  of  our  agent. 


TREATMENT  OF  TUBERCULOSIS  197 

I  have  also  used  stasis  hyperemia  in  tuberculosis  of 
bones,  tendon  sheaths,  glands,  skin  and  subcutaneous 
:ellular  tissue  and  also  lupus  of  the  skin.  Concerning  the 
tuberculosis  of  tendon  sheaths  my  experience  is  very 
limited.  I  have  seen  considerable  improvement  follow 
the  use  of  stasis  hyperemia,  but  never  a  complete  cure, 
and  gladly  give  up  this  treatment  because  extirpation 
of  the  affected  tendon  sheaths  leads  to  the  purpose  more 
rapidly  and  shows  good  functional  results.  In  pure 
tuberculosis  of  the  bone,  as  a  rule,  I  remove  by  operation 
the  focus  if  it  can  be  foreseen  that  the  function  of  the 
corresponding  limbs  will  not  be  damaged  by  the  opera- 
tion. As  regards  glandular  tuberculosis  the  cubital  gland 
is  really  the  only  one  suited.  The  treatment  is  without 
practical  importance  and  I  will,  therefore,  omit  it. 
,  I  have  seen  no  results  or  only  transient  improvement 
from  the  treatment  of  lupus  with  pure  bandage  stasis. 
On  the  other  hand,  I  have  repeatedly  produced  cures  of 
ulcerated  lupus  of  the  face  with  stasis  hyperemia  pro- 
duced by  cupping  glasses.  But  this  treatment,  too,  is  of 
no  practical  value,  as  extensive  facial  lupus  can  not  be 
treated  in  this  manner,  while  small  lupous  foci  are  best 
.excised  and  the  wound  margins  sutured.  Besides,  Fin- 
sen's  photo-therapy  excels  this  process. 

Jacoby  (205)  has  made  the  attempt  to  cure  pulmonary 
tuberculosis  by  hyperemia.  He  followed  my  idea  which 
led  me  to  the  treatment  of  surgical  tuberculosis,  and  in 
principle  he  worked  with  the  same  agents  with  which  I 
treated  tuberculosis  in  the  beginning.  He  places  the 
lung  apices  low  and  affects  the  chest  by  a  bath  in  hot 
, water.  Though  I  have  repeatedly  asserted  that  the  ac- 
tive hyperemia  by  heat  is  unfit  for  the  treatment  of  tuber- 
culosis, I  do  not  wish  to  say  that  here  the  hot  water  could 
not  favorably  influence  the  disease.  For,  as  I  have 
already  pointed  out,  hot  water  belongs  to  the  agents  that 
produce  a  less  intense  hyperemia.  To  this  must  be  added 
that  the  deeply  situated  tubercular  foci  on  account  of  the 
peculiar  "inflammatory  irritation"  are  capable  of  retard- 
ing a  blood-current  flowing  fairly  "rapidly. 

I  know  of  a  simpler  remedy  to  make  the  lungs  hyper- 
emic  for  a  definite  period,  viz.,  inhalation  of  thinned  air. 
This  could  be  easily  fulfilled  with  apparatus,  but  it  no 


198  TREATMENT  OF  TUBERCULOSIS 

doubt  would  be  simpler  to  compress  the  nostrils  with  the 
fingers  and  to  advise  the  patient  to  deeply  inhale  through 
the  nose  and  to  exhale  through  the  mouth  so  that  he  be- 
comes asphyxiated  enough  to  bear  it.  As  far  as  I  know 
this  has  not  yet  been  tried,  while  consumptives,  basing 
on  different  presuppositions,  were  permitted  to  exhale  in 
thinned  air,  a  process  which  now  has  undoubtedly  been 
dropped. 


CHAPTER  XIX 

TREATMENT    OF    ACUTE    AND    SUBACUTE 
ARTHRITIS. 

Among  the  acutely  inflamed  joints  for  which  treatment 
with  stasis  hyperemia  is  applicable,  I  mention  in  the  first 
place  the  arthritis  of  gonorrhoics.  I  have  treated  with 
this  remedy  various  forms  of  this  inflammation  and  have 
seen  the  best  results  in  such  cases,  for  which  heretofore 
we  lacked  a  remedy  and  which  are  so  grave  that  they 
lead  to  ankylosis  or  at  least  to  the  severest  stiffness,  and 
which  Koenig  named  "phlegmonous."  As  is  known, 
aside  from  the  joint  proper  also  the  structures  near  it, 
especially  the  tendons,  are  involved.  These  cases  are 
characterized  by  intense  pain. 

I  know  of  no  other  remedy  which  has  as  prompt  an 
effect  in  any  disease  as  the  hot  stasis,  which  can  be  very 
easily  produced  in  such  cases.  An  hour  after  the  applica- 
tion of  the  remedy  the  pain  is  greatly  diminished,  and 
in  cases  in  which  the  least  touch,  especially  an  attempt 
to  move  the  stiff  fingers,  is  accompanied  by  maddening 
pain,  any  motion  being  simply  an  impossibility,  to  the 
greatest  surprise  of  the  patients,  careful  passive  motions 
can  be  undertaken  and,  what  is  more  important  still, 
without  any  injury  for  the  patient.  The  patient  soon 
learns  the  advantage  and  agreeableness  of  the  remedy 
and  asks  for  the  stasis  bandage  when  it  is  kept  off  for 
some  time.  It  has  proved  itself  the  best  hypnotic  when 
worn  during  the  night,  and  has  given  longed-for  rest 
to  sufferers  who  have  been  unable  to  find  any  sleep  in 
spite  of  powerful  narcotics. 

At  first  I  had  good  results  in  such  cases  with  the 
permanent  application  of  stasis  hyperemia  save  a  two- 
hour  interval  per  day.  Of  late  I  have  prolonged  the 
intervals  and  have  reduced  the  stasis  hyperemia  to  one 
half  hour,  but  have  become  convinced  that  this  is  not 
sufficient.  In  the  graver  cases  the  bandage  has  to  be 
worn  at  least  from  ten  to  twelve  hours  daily  and,  as  a 
rule,  even  longer.  On  account  of  the  rest  I  order  the 
bandage  worn  over  night,  although  it  can  not  be  watched 
very  carefully.  The  bandage  should  be  applied  an  hour 

199 


200  TREATMENT  OF   ARTHRITIS 

before  retiring  in  order  to  be  convinced  that  it  does  its 
duty.  In  the  gravest  forms  even  a  daily  treatment  of 
from  ten  to  twelve  hours  is  not  sufficient.  In  such  cases 
I  order  the  bandage  worn  throughout  the  day  with  the 
exception  of  a  two-hour  interval.  The  stasis  must  be 
vigorous,  but  in  these  cases  particularly  the  axiomatic 
law  holds  good  that  this  remedy  must  diminish,  not  in- 
crease the  pain.  One  must  not"  be  content  until  vigorous 
stasis  and  diminution  of  pain  have  been  achieved.  For- 
tunately in  acute  inflammation  this  is  easy.  A  bandage 
applied  relatively  loose  produces  very  intense  and  hot 
stasis  and  relieves  the  pain  instantaneously.  I  at  once 
commence  with  careful  passive  and,  as  soon  as  possible, 
active  motions,  which,  as  already  mentioned,  is  possible 
with  our  remedy.  Splints  are  used  only  in  the  intervals 
when  the  bandage  is  not  applied  or  during  the  night  when 
the  pain  is  still  intense.  In  the  intervals  the  limb  is  ele- 
vated in  order  to  diminish  the  old  edema  and  to  permit  a 
new  one  to  take  its  place. 

Stasis  hyperemia  has  never  failed  me  in  the  grave 
forms  of  gonorrheal  arthritis  and  the  successes  as  re- 
gards rapidity  of  cure  and  the  function  of  the  extremities 
are  brilliant  as  compared  with  anything  that  I  have  ever 
seen  before.  In  Kiel  these  cases  were  not  infrequent  and 
my  teacher,  von  Esmarch,  used  to  treat  them  with  plaster 
of  paris  cast.  Though  the  latter  was  removed  as  soon 
as  the  affection  permitted  this,  ankylosis,  or  at  least 
severe  stiffness,  was  the  rule. 

I  have  also  employed  stasis  hyperemia  in  mild  forms 
of  gonorrheal  arthritis  but  not  with  the  same  regular  suc- 
cesses as  in  those  grave  forms,  which  fortunately  are  ex- 
cellently suitable  for  treatment  with  stasis  hyperemia. 
In  order  to  illustrate  the  effects  of  this  remedy,  I  will 
cite  one  case  which  has  been  treated  successfully  and 
one  where  success  was  not  obtained : 

A  man,  twenty  years  old,  was  attacked  three  months 
prior  to  admission  by  a  gonorrhea.  Five  weeks  ago  he 
suddenly  began  to  suffer  with  pain  in  the  right  wrist 
which  robbed  him  of  his  sleep.  A  physician  who  was 
called  pronounced  it  a  case  of  acute  articular  rheuma- 
tism, enveloped  the  joint  in  cotton,  treated  it  with  the 
ice-bag  and  finally  applied  iodine  until  the  skin  became 


EJDF/vTK 

TREATMENT  OF  ARTHRITIS  201 

inflamed  and  cracked.  When  all  this  proved  useless,  the 
extremity  was  bandaged  to  a  splint  which  the  patient  has 
worn  for  the  last  four  weeks.  This  all  without  any  re- 
sult. 

The  patient  was  admitted  July  9,  1902.  T.he  region  of 
the  right  wrist  was  very  much  swollen;  the  circum- 
ference of  the  wrists  was,  on  the  right  one  25^/2  and 
on  the  left  one  iS^cm.  The  back  of  the  hand  was 
edematous,  which  could  be  followed  up  to  the  region  of 
the  elbow-joint.  The  palm  was  filled  in.  Redness  of 
the  skin  was  absent.  The  fingers  were  fixed  in  exten- 
sion ;  the  hand  in  pronation.  The  region  of  the  wrist  and 
of  the  extensor  tendons  was  extremely  sensitive  to  touch, 
the  least  attempt  to  move  the  wrist  or  the  fingers  caused 
the  patient  to  cry  out  aloud.  He  asserted  to  have  slept 
for  the  last  weeks  through  the  day  not  at  all  and  during 
the  night  very  little,  because  the  pain  in  the  wrist,  in 
spite  of  its  being  fixed  to  a  splint,  was  unbearable.  He 
was  in  a  poor  general  state.  The  joint  between  carpal 
and  metacarpal  bones  was  extrejnely  sensitive  to  touch. 
The  Roentgen  picture  shows  each  metacarpal  bone  sur- 
rounded by  a  broad  bright  margin.  It  looks  as  if  each 
of  them  were  surrounded  by  a  layer  of  cotton  and  therein 
placed  alongside  each  other.  The  upper  ends  of  the  sec- 
ond to  fifth  metacarpal  bones  show  the  most  decided 
changes.  Their  articular  ends  are  attacked  by  caries 
and  show  periosteal  granulations.  But  neither  they  nor 
the  bones  of  the  fingers  show  the  a-trophic  changes  usual- 
ly accompanying  inflammation  of  the  joints.  The  soft 
parts  of  the  arm  are  atrophic,  while  those  of  the  forearm 
can  not  be  made  out  on  account  of  the  edema.  The  pa- 
tient still  had  a  discharge  from  the  urethra  containing 
gonococci.  He  had  no  fever. 

The  affected  limb  was  fastened  to  a  splint  and,  first  of 
all,  elevated  until  the  next  morning  in  order  to  diminish 
the  edema  and  to  enable  a  more  detailed  examination. 
In  this,  however,  we  did  not  succeed,  the  circumference 
yielding  on  the  morning  of  July  loth  the  same  result. 
At  8 145  the  same  morning  the  stasis  bandage  was  ap- 
plied to  the  arm.  After  an  hour  the  patient  had  no 
more  pain.  To  the  greatest  surprise  of  the  patient,  slight 
passive  movements  were  possible  without  pain  in  the 


Ml-iT/'SU7!.]  if  6  '  nO  -"5'tD  T  'I 

202  TREATMENT  OF   ARTHRITIS 

. 

wrist-joint  and  the  fingers.  At  9:45  the  bandage  was 
removed  and  reapplied  from  10:45  to  2.  p.  m.  In  the 
evening  he  wore  it  again  from  7:30  to  10:30,  and  during 
this  time  the  patient  had  the  first  deep,  uninterrupted 
sleep  for  a  long  while.  Soon  after  the  removal  of  the 
bandage  the  pain  came  back  so  that  the  patient  could 
not  sleep. 

In  the  morning  of  July  nth  the  joint  again  became 
painful  and  sensitive  to  touch.  The  bandage  was  worn 
from  8 145  to  I  p.  m. ;  after  it  was  worn  for  twenty  min- 
utes the  pain  disappeared  but  reappeared  an  hour  after 
the  removal  of  the  bandage.  Stasis  hyperemia  was  again 
maintained  from  7  p.  m.  to  8  p.  m. ;  it  produced  a  strong 
redness,  swelling  and  heat  in  the  affected  limb.  The 
patient  had  slept  from  9:30  to  4  uninterruptedly.  There 
was  no  pain  on  pressure,  passive  motions  of  the  wrist  and 
fingers  were  possible  to  a  great  extent. 

July  I2th  the  patient  wore  the  stasis  bandage  from 
ii  :45  until  9:30  of  the  following  morning.  In  the  mean- 
time it  was  fastened  on  a  different  place.  He  slept 
throughout  the  entire  night. 

The  bandage  was  again  applied  without  interruption 
from  5  p.  m.  July  I3th  to  II 130  a.  m.  July  I4th.  Since 
then  pain  in  the  wrist  did  not  appear  even  in  the  intervals 
during  which  no  hyperemia  was  maintained,  and  pres- 
sure elicited  some  pain  only  in  the  joint  between  meta- 
carpus and  carpus.  The  patient  commenced  to  actively 
move  wrist  and  fingers.  Supination  was  still  rather 
painful,  which  now  was  undertaken  in  a  great  measure. 
After  the  bandage  was  off  for  eight  hours,  the  circum- 
ference of  the  affected  joint  was  again  measured,  show- 
ing 23.5  cm. ;  therefore,  there  was  a  gain  in  spite  of  the 
hyperemia  of  but  2  cm.  The  diminution  of  the  swelling 
was  also  recognizable  by  the  wrinkled  condition  of  the 
skin.  The  improvement  of  the  disease  progressed  stead- 
ily while  the  time  of  the  hyperemia  was  gradually  short- 
ened. July  22d  we  commenced  slight  massage,  which 
was  stopped  on  the  28th  because  it  left  some  pain. 

August  ist  the  patient  was  referred  for  treatment  in 
the  dispensary  with  the  following  status:  The  circum- 
ference of  the  right  wrist  is  19^  cm.  (decrease  since 
July  loth,  524cm.),  and  is  I  cm.  larger  than  the  healthy 


TREATMENT  OF  ARTHRITIS  203 

wrist.  The  swelling,  which  is  still  present,  feels  firm 
and  hard.  Pains  can  be  elicited  only  by  strong  pressure 
on  the  joint  between  carpus  and  metacarpus.  Active 
flexion  of  the  hand  is  almost  entirely  free,  rotation  en- 
tirely free ;  extension,  on  the  other  hand,  is  still  very 
limited.  The  ringers  can  be  bent  up  to  2.  cm.  from  the 
palm  and  thoroughly  extended.  In  the  polyclinic  (dis- 
pensary) a  daily  application  of  stasis  hyperemia  for  one 
hour  was  given  up  to  August  5th  and  then  massage  was 
added,  while  the  hyperemia  was  applied  only  half  an  hour 
daily.  A  few  days  later  the  patient  withdrew  from  fur- 
ther treatment  and  observation ;  at  that  time  he  was  en- 
tirely free  from  pain  and  could  bend  the  fingers  into  a 
fist. 

This  case  shows  that  the  short  hyperemia  which  we 
described  as  the  most  useful  for  tuberculosis  is  not  suf- 
ficient for  the  grave  gonorrheal  inflammation  of  joints. 
Though  the  bandage  removed  the  pain  while  it  was  on, -it 
reappeared  soon  after  the  removal  of  the  bandage;  a 
decided  success  was  only  obtained  when  we  employed 
prolonged  stasis  hyperemia. 

In  a  second  similar  case,  though  not  quite  as  grave  as 
the  former,  we  had  the  same  experience  in  a  still  more 
decided  manner.  In  this  case  we  achieved  success  only 
when  we  applied  the  stasis  hyperemia,  as  we  were  used 
in  the  beginning,  for  twenty-two  hours  daily ;  especially 
was  sleep  only  obtained  when  we  permitted  the  patient 
to  wear  the  bandage  throughout  the  night. 

The  following  case  of  a  mild  form  of  gonorrheal 
arthritis  shows  a  lack  of  success  with  the  treatment  by 
stasis  hyperemia. 

A  man,  aged  twenty-two,  contracted  three  weeks  ago  a 
gonorrheal  urethritis.  A  week  later  he  experienced  pain 
in  the  left  foot,  which,  after  the  application  of  warm 
compresses  and  inunction  with  tincture  of  arnica,  disap- 
peared to  such  an  extent  that  he  could  walk  with  the 
aid  of  a  cane.  As  the  pain  got  worse  on  walking  and 
appeared  also  in  the  left  knee  and  a  lymphangitis  was 
added,  the  patient  entered  the  clinic  August  29,  1901.  The 
dorsum  of  the  left  foot  was  swollen,  Chopart's  and  Lis- 
franc's  joints  were  very  sensitive  to  pressure.  Extension 
of  the  foot  was  unimpeded,  flexion  limited,  pro-  and 


204  TREATMENT  OF  ARTHRITIS 

supination  almost  suspended.  The  left  knee  joint  was 
contracted  in  flexion  and  was  very  painful;  objective 
changes,  however,  could  not  be  noticed.  Lymphangitic 
stripes  could  be  observed  from  the  foot  to  the  lower  third 
of  the  thigh.  The  patient  had  a  discharge  from  the 
urethra  containing  gonococci  and  slight  fever. 

Up  to  November  2d  Priessnitz's  compresses  were  ap- 
plied, which  produced  no  improvement  whatever.  From 
November  2d  to  November  5th  stasis  hyperemia  was  em- 
ployed throughout  the  day  with  intervals  of  several  hours, 
also  without  any  success,  save  that  the  affection  of  the 
knee  disappeared  entirely,  and  the  lymphangitis  almost 
entirely.  The  stasis  hyperemia  in  this  case,  however, 
remained  without  any  influence  whatever  on  the  pain  in 
the  ankle,  for  which  reason  no  success  was  expected  from 
it.  It  was  stopped  after  a  use  of  three  days.* 

Applications  of  tincture  of  iodine  and  hot  air  proved 
useless,  the  latter  even  aggravating  the  pain  during  the 
night ;  a  plaster  of  paris  cast  was  applied  December  ist, 
which  removed  the  pain  in  a  few  days. 

Though  this  case  does  not  represent  a  grave  form  of 
gonorrheal  arthritis,  the  stasis  hyperemia  remained  with- 
out any  influence  on  the  pain  of  the  affected  ankle.  We 
can  see  that  this  remedy,  which  has  so  miraculous  an 
effect  in  this  disease,  remains  useless  in  exceptional 
cases.  I  suppose  that  this  is  due  to  the  blood  which  the 
patient  places  at  our  disposal.  However,  the  few  failures 
can  not  decrease  the  merits  of  the  remedy  for  gonorrheal 
affections  of  the  joints,  as  it  helps  even  in  the  gravest 
forms,  when  all  our  remedies  frequently  leave  us  in  the 
lurch,  at  least  in  regard  to  the  re-establishment  of  good 
function.  Indeed,  I  hardly  know  a  remedy  which  makes 
such  an  impression  on  the  physician  and  patient  as  does 
the  stasis  hyperemia  in  the  gravest  cases  of  gonorrheal 
arthritis.  When  everything  else  has  failed  its  beneficent 
effect  can  be  noticed  even  within  half  an  hour.  I  can 
understand  why  stasis  hyperemia  has  been  dropped  as  a 
remedy  in  tuberculosis,  because  the  technic  has  its 
peculiarities  and  because  previous  to  the  introduction  of 

*This  was  too  soon.  Recently  I  observed  a  grave  case  of 
gonorrheal  arthritis  of  the  knee  in  which  success  came  only 
after  weeks,  but  then  completely. 


TREATMENT  OF  ARTHRITIS  205 

the  short-time  stasis,  this  agent  has  been  improperly  ap- 
plied, thus  producing  aggravation  of  the  trouble,  but  I 
do  not  understand  why  it  is  not  employed  in  gonorrheal 
joints.  For,  though  I  have  recommended  the  remedy 
for  it  in  1894,  and  later  have  repeatedly  called  attention 
to  it,  I  know  of  no  contribution  on  it  from  any  other 
source.  From  this  one  can  conclude  that  in  a  time 
when  the  desire  to  publish  experiences  is  prevalent,  the 
stasis  hyperemia  has  not  been  employed  against  gonor- 
rheal arthritis  to  any  great  extent.'  And  this  when  the 
success  obtained  is  so  prominent  and  the  technic  so  sim- 
ple. One  simply  goes  according  to  the  sensation  by  the 
patient,  instructing  him  that  he  must  have  no  trouble 
with  the  bandage  and  that,  on  the  contrary,  the  trouble 
must  be  diminished ;  and  with  a  comparatively  loose  ap- 
plication one  can  obtain  without  difficulty  the  desired 
hot  stasis. 

I  must  remark  that  I  have  never  treated  hydrops  of 
the  joints  of  gonorrhoics  with  stasis  hyperemia,  and  that 
I  have  caused  to  disappear  with  this  remedy  the  dry 
forms  of  this  articular  inflammation  within  a  few  days. 
I  have  been  similarly  successful  with  stasis  hyperemia 
in  other  acute  inflammations  of  the  joints.  In  acute 
articular  rheumatism,  of  which,  to  be  sure,  I  have  treated 
only  ten  cases,  the  patients  unanimously  remarked  that 
the  pain  quickly  disappeared  after  the  application  of  the 
stasis  bandage.  The  joints  which  have  been  subjected 
to  stasis  hyperemia  showed  regularly  a  more  rapid  retro- 
gression of  the  other  disease  phenomena  than  those  which 
have  not  been  so  treated.  However,  the  number  of  the 
cases  is  so  small  and  acute  rheumatism  is  so  contrary  a 
disease  that  the  joints  which  look  serious  to-day  may  al- 
most appear  cured  the  next  day,  so  that  positively  final 
conclusions  can  not  be  drawn.*  The  treatment  is  the 
same  as  in  gonorrhea  of  the  joints. 

I  have  observed  the  best  results  in  all  kinds  of  acutely 
and  especially  subacutely  diseased  joints  after  treatment 
with  stasis  hyperemia.  Thus,  I  have  cured  with  it  two 
cases  of  grave  puerperal  inflammation  of  the  knee-joint 

•Stasis  hyperemia  has  been  successfully  made  use  of  since 
the  above  was  written  in  several  hospitals  for  acute  articular 
rheumatism. 


206  TREATMENT  OF   ARTHRITIS 

which  had  existed  for  weeks,  with  very  satisfactory  re- 
sults in  regard  to  function.  This  means  a  good  deal,  be- 
cause, as  a  rule,  these  cases  lead  to  stiff  joints.  Of  late  I 
have  treated  the  following  case  of  traumatic  arthritis, 
which  seems  worthy  of  mention : 

An  owner  of  a  farming  estate,  aged  twenty-six,  sus- 
tained an  injury  to  the  right  knee-joint  by  a  fall  from  a 
bicycle,  which  resulted  in  suppuration,  though  the  fever 
and  inflammation  were  not  very  pronounced.  He  was 
admitted  in  the  surgical  clinic  June  24th.  We  found 
above  the  patella  a  wound  about  3  cm.  long  situated 
across  the  limb.  In  the  joint  was  considerable  effusion. 
On  pressure  serous  pus  escaped  from  the  wound.  The 
patient  had  pain  in  the  knee  but  could  limp.  He  had  no 
fever. 

June  26th  stasis  hyperemia  was  instituted  and  em- 
ployed two  hours  daily ;  it  immediately  caused  the  pain 
in  the  knee  to  disappear.  June  3Oth  no  more  pus  was 
evacuated  from  the  wound,  and  the  patient  was  dis- 
charged July  8th  with  a  normally  functionating  knee 
without  effusion,  after  use  of  stasis  hyperemia  for  only 
twelve  days.  The  wound  was  entirely  closed  save  a 
superficial  stripe  of  granulation. 

The  following  case  also  seems  worthy  of  mention : 

I  treated  in  1893  a  child  which  was  acutely  attacked 
by  a  high  fever.  After  some  time  appeared  an  inflamma- 
tion of  the  knee,  which  was  soon  followed  by  a  turbid, 
coagulating  effusion.  The  lower  end  of  the  femur  was 
thickened  and  painful.  The  high  fever  disappeared,  but 
a  moderate  temperature  and  the  inflammation  in  the 
knee  remained  and  the  latter  did  not  improve  though  the 
joint  was  treated  antiphlogistically  and  was  aspirated  and 
washed  out.  The  joint  very  soon  became  stiff  and  sen- 
sitive. I  instituted  stasis  hyperemia,  which  appeared  in 
its  most  intense  form.  With  one  stroke  the  disease  im- 
proved ;  in  a  few  days  fever,  effusion  and  inflammation 
disappeared  and  the  joint  became  mobile.  Probably  we 
had  here  to  deal  with  a  case  of  mild  acute  osteo-myelitis 
of  the  lower  end  of  the  femur,  which  involved  the  neigh- 
boring joint.  I  do  not  employ  stasis  hyperemia  in  larger 
abscesses  of  the  joints,  but  have  employed  it  success- 
fully in  such  cases  as  after  treatment,  when  by  means 


TREATMENT  OF  ARTHRITIS  207 

of  aspiration  and  irrigation  with  antiseptic  liquids  suppu- 
ration has  been  checked,  pain  and  stiffness  of  the  joints 
remaining. 

The  duration  of  hyperemia  in  non-gonorrheal  inflam- 
mation of  the  joints  depends  on  each  individual  case.  In 
one  case  the  application  of  the  bandage  for  one  to  two 
hours  is  sufficient,  again  in  most  cases  it  has  to  be  applied 
for  from  eighteen  to  twenty-three  hours  daily.  In  these 
cases,  too,  it  should  not  be  employed  permanently  and 
in  the  intervals  the  limb  is  to  be  postured  high  in  order 
to  remove  the  old  edema  as  much  as  possible.  I  act  in 
these  cases  essentially  in  accordance  with  the  objective 
condition  of  the  patients ;  if  he  states  that  after  a  short 
period  of  stasis  the  pain  disappears  and  the  restricted  mo- 
tion improves,  I  limit  the  application  of  the  bandage  to 
one  to  two  hours  daily.  If  the  patient  states  that  soon 
after  the  removal  of  the  bandage  the  pain  reappears,  I 
employ  the  remedy  longer.  Many  patients  ask  that  the 
bandage  be  reapplied  because  it  produces  subjectively 
improvement.  The  suction  apparatus  can  not  be  em- 
ployed in  acute  and  subacute  inflammation  of  the  joints 
on  account  of  the  intense  effect. 

I  consider  stasis  hyperemia  the  best  form  of  hyperemia 
which  can  be  employed  in  the  affections  under  discus- 
sion. The  active  hyperemia,  as  produced  by  hot  air,  in 
these  affections,  as  well  as  in  tuberculosis,!  consider  use- 
less and  refer  the  reader  in  this  respect  to  what  I  have 
said  in  Chapter  XIII.  I  had  an  opportunity,  a  short 
while  ago,  to  be  convinced  of  the  superiority  of  passive 
hyperemia  over  the  active  form  in  a  case  of  phlegmonous 
gonorrheal  joint. 

A  girl,  nineteen  years  old,  ten  weeks  previous  to  admis- 
sion, was  suddenly  attacked  with  violent  pains  in  the  left 
wrist  and  was  treated  for  it  in  a  different  hospital  for 
several  weeks  with  hot  air.  The  joint  became  gradually 
stiffer  and  the  sensitiveness  did  not  diminish.  She  was 
received  at  the  surgical  clinic  September  28,  1900,  The 
left  wrist  was  but  little  swollen,  and  measured  I  cm. 
more  than  the  other.  The  skin  was  red,  the  joint  on  the 
dorsal  side  of  the  hand  very  sensitive  to  pressure ;  it  was 
in  slight  flexion  and  pronation  and  each  attempt  at  flexion 
elicited  violent  pain.  Stasis  hyperemia  was  used  from 


208  TREATMENT  OF  ARTHRITIS 

September  28th  to  October  28th  throughout  each  day 
and  this  removed  the  pain  in  a  few  days  so  that  soon 
passive  motions  and  later  active  motions  could  be  exe- 
cuted. When  discharged  the  joint  could  be  flexed  and 
extended  to  50°  and  actively  rotated  without  pain.  The 
affected  limb  became  usable. 


CHAPTER  XX 

TREATMENT  OF  OTHER  FORMS  OF  ACUTE 
INFLAMMATION 

A  remedy  which  gives  good  results  in  acute  inflamma- 
tion of  the  joints  is  naturally  applicable  to  such  of  the 
soft  parts.  I  have  employed  it  in  several  cases,  so,  for 
instance,  for  an  endemic  outbreak  of  facial  erysipelas, 
which  we  had  in  the  poorly  constructed  hospital  in 
Greifswald.  In  thirteen  cases  I  used  the  stasis  bandage, 
which  was  so  tightly  drawn  around  the  neck  that,  while 
producing  no  trouble,  it  created  a  vigorous  hot  stasis  of 
the  face  with  intense  redness  and  swelling  of  the  skin. 
In  only  one  case  did  the  erysipelas  extend  to  the  bandage  ; 
in  the  rest  the  disease  remained  remarkably  limited.  The 
average  duration  of  the  disease  was  four  to  nine  days. 

In  the  cases  so  treated  the  improvement  of  the  general 
condition,  the  rapid  fall  of  temperature  and  the  rich 
desquamation  which  appeared  early  were  striking.  In- 
asmuch as  erysipelas  is  an  uncertain  malady,  it  is  quite 
possible  that  accidentally  I  met  very  mild  cases  and  for 
this  reason  the  suppression  of  phlegmon,  which  we  have 
succeeded  in  accomplishing  with  this  remedy  several 
times,  is  of  more  value.  I  cite  here  the  most  brilliant  of 
these  cases,  though  I  have  published  it  once  before. 

A  butcher,  aged  forty-three,  November  2nd  sustained 
a  wound  2  mm.  wide  across  the  small  finger  of  the  left 
hand.  He  worked  with  it  up  to  November  5th  without 
paying  attention  to  the  wound.  It  finally  became  in- 
flamed and  the  patient  called  three  times  on  a  physician, 
who  incised  it  each  time.  November  nth  he  came  to  the 
hospital  because  the  condition  got  suddenly  worse  fol- 
lowing the  last  incision.  On  the  flexor  side  of  the  small 
finger  in  the  region  of  the  second  part  was  found  a  cross 
wound  in  which  a  tendon  was  exposed.  The  entire  re- 
gion of  the  flexor  tendons  of  the  small  fingers  was  ex- 
tremely painful  on  touch  up  to  the  wrist.  If  we  pressed 
over  the  sheath  of  the  flexor  tendon  from  the  wrist- 
joint  towards  the  wound,  a  discolored,  watery  liquid  ap- 
peared at  the  wound.  The  ulnar  part  of  the  skin  of  the 
region  of  the  wrist  and  3  cm.  upwards  was  very  red  and 

14  209 


210  TREATMENT  OF  ACUTE  INFLAMMATION 

sensitive  to  pressure.  The  joint  between  the  first  and 
second  part  of  the  little  ringer  was  open.  We  discovered 
an  extensive  lymphangitis  of  the  forearm  and  swelling  of 
the  cubital  gland.  General  condition  was  bad ;  pain  se- 
vere. Immediately  while  in  the  dispensary  before  even 
being  admitted  to  the  hospital  at  n  a.  m.  of  the  same 
morning  (November  nth)  a  stasis  bandage  was  applied 
to  the  arm,  while  the  patient  had  a  temperature  of  39°  C. 
taken  in  the  axilla.  It  cost  quite  an  effort  to  produce  the 
right  kind  of  hot  stasis  without  also  producing  pain. 
When  this  was  attained  the  pain  soon  disappeared.  The 
painful  and  stiff  little  finger  could  now  be  bent  by  the  pa- 
tient. The  stasis  was  continued  to  4  p.  m.,  then  removed. 
As  this  all  was  done  previous  to  admission,  no  exact 
record  of  his  temperature  was  obtained. 

After  removal  of  the  stasis  bandage  pain  reappeared 
quickly.  At  6:45  p.  m.  patient  had  a  chill.  The  bandage 
was  then  reapplied.  Again  it  cost  a  great  effort  and  dif- 
ficulty to  obtain  the  right  hot  stasis  without  pain.  After 
this  was  attained  the  pain  disappeared  rapidly,  the  tem- 
perature sank  at  8:30  p.  m.  to  38°  C.  and  at  10  p.  m.  to 
38.7°  C.  At  10  in  the  evening  the  bandage  was  removed 
for  a  short  while,  then  reapplied  and  worn  until  4  a.  m. 
When  the  stasis  edema  became  somewhat  lessened  it 
could  be  seen  that  the  swelling  and  redness  at  the  wrist 
had  disappeared,  as  did  the  lymphangitis  ;  only  the  region 
of  the  flexor  tendon  of  the  small  finger  was  still  sensitive. 

November  I2th  the  stasis  bandage  was  worn  from  9  to 
i,  from  5  to  8:30  and  from  10:30  p.  m.  to  10  a.  m.  of 
November  I3th.  After  this  the  disease  was  essentially 
removed,  the  swelling  had  diminished,  only  some  sensi- 
tiveness remained  in  the  above-named  place.  With  large 
intervals  the  stasis  hyperemia  was  continued  to  Novem- 
ber I5th.  The  temperature  did  not  rise  November  I2th 
over  38.6°  C. ;  November  I4th  not  over  37.7°  C.,  and  was 
normal  since  November  I5th.  Small  superficial  tendon 
shreds  were  expelled  from  the  wound,  which  healed 
quickly.  The  suppurating  joint  remained  somewhat  stiff 
and  had  crepitation  on  motion  but,  on  the  whole,  the  dis- 
ease was  removed  without  any  disturbance  of  the  func- 
tion of  the  hand. 

This  is  a  very  important  case  in  so  far  as  it  represents 


mm  m  «m 


Fie.  10. 


212  TREATMENT  OF   ACUTE   INFLAMMATION 

one  of  the  dreaded  cases  of  phlegmon  of  the  sheath  of  the 
flexor  tendon  of  the  fifth  finger,  which  under  the  most 
favorable  circumstances  terminate  in  a  mutilation  and 
grave  functional  disturbance  of  the  hand.  To  be  sure, 
we  had  here  a  favorable  case,  as  the  tendon  sheath  was 
probably  only  infected  at  the  incision  undertaken  for  the 
evacuation  of  the  pus,  shortly  before  the  patient's  admis- 
sion. 

The  following  case  of  acute  inflammation  which  has 
been  treated  with  stasis  hyperemia  and  which,  too,  has 
been  published  by  me  before,  is  instructive  in  a  some- 
what different  direction : 

A  smith  apprentice,  aged  eighteen,  became  acutely  af- 
fected March  10,  1901,  with  pain,  swelling  and  redness 
of  the  right  knee-joint  without  an  external  injury.  He 
had  to  go  to  bed  and  passed  a  sleepless  night.  He  was 
treated  with  compresses  of  alumen  acetate. 

He  entered  the  clinic  March  I4th.  The  entire  region 
of  the  knee-joint  was  red  and  inflamed.  The  redness  ex- 
tended almost  to  the  middle  of  the  leg.  The  knee-joint 
itself  was  not  involved  nor  the  bursa  praepatellaris. 
There  was  an  intense  lymphangitis  on  the  thigh,  but  the 
greatest  pain  was  at  the  inner  side  of  the  knee-joint. 
This  was  in-  slight  flexion  and  an  attempt  to  extend  it 
produced  pain.  The  swelling  was  so  intense  that  the 
circumference  of  the  affected  limb  at  the  swollen  place 
exceeded  that  of  the  healthy  extremity  by  over  5  cm. 
An  abscess  could  not  be  demonstrated.  The  general 
condition  of  the  patient  was  very  much  disturbed ;  he 
was  delirious  during  the  first  night  and  jumped  out  of 
bed,  so  that  he  had  to  be  watched.  The  next  morning 
the  use  of  stasis  hyperemia  was  begun.  The  desired  hot 
form  was  achieved.  The  accompanying  curve  (see  Fig. 
10)  illustrates  the  time  during  which  this  remedy  was 
employed  and  its  influence  on  the  temperature.  The 
dotted  line  represents  the  time  during  which  the  remedy 
was  employed.  On  the  whole  the  course  of  the  disease 
was  as  follows :  Immediately  after  the  institution  of 
stasis  the  pain  diminished.  In  the  following  night  the 
patient  was  still  restless,  in  the  subsequent  one  he  slept 
quietly.  The  pain  (even  on  pressure)  and  the  general 
condition  of  malaise  had  fairly  disappeared  since  March 


TREATMENT   OF   ACUTE   INFLAMMATION  213 

i6th.  Since  March  igth  temperature  was  normal.  In 
spite  of  this  an  abscess  formed  on  the  outer  side  of  the 
leg  below  the  knee-joint,  which  was  opened  March  25th. 
It  contained  chocolate-colored  pus,  from  which  a  pure 
culture  of  streptococci  was  obtained.  Two  rabbits  which 
were  inoculated  with  it  at  the  ear  became  erysipelatous 
with  lymphangitis  and  lymphadenitis.  In  both  the  dis- 
ease took  a  moderate  course  and  the  animals  escaped  with 
their  lives. 

Therefore  in  this  case  the  stasis  hyperemia  did  by  no 
means  kill  the  bacterial  factors,  but  it  seems  that  their 
virulency  was  weakened.  I  especially  call  attention  to 
the  influence  of  the  stasis  hyperemia  on  the  temperature, 
which  can  be  appreciated  from  the  figure  without  any 
trouble.  But  I  emphatically  warn  that  it  is  not  advisable 
for  any  physician  to  apply  stasis  hyperemia  in  such  cases, 
unless  he  has  acquired  a  familiarity  with  the  remedy  in 
other  affections,  and  that  the  remedy  is  suitable  in  such 
cases  only  when  seen  early.  I  am  convinced  that  the 
greatest  mischief  can  be  produced  with  the  remedy  in 
progressed  cases  of  phlegmon  of  the  soft  parts.  The  cir- 
culatory disturbance  in  such  cases  is  so  pronounced  that 
gangrene  of  the  attacked  parts  is  threatening,  in  which 
cases  the  removal  of  the  blood-stasis  is  indicated  and  not 
an  increase  of  the  latter. 

Therefore,  even  he  who  sees  many  of  such  cases  would 
but  rarely  find  a  suitable  one  for  this  remedy.  More  de- 
tailed rules  I  can  not  lay  down,  because  my  experience  in 
such  cases  is  limited,  it  being  more  in  the  form  of  experi- 
ments. In  several  cases  which  appeared  to  me  as  suit- 
able for  stasis  treatment  I  have  refrained  from  using  the 
remedy  when  improvement  did  not  occur  immediately 
after  the  application  of  the  bandage. 


CHAPTER  XXI 

TREATMENT    OF   CHRONIC   STIFF   JOINTS 

The  successes  achieved  with  the  treatment  by  hyper- 
emia,  both  active  and  passive,  in  all  forms  of  chronic  stiff 
joints,  be  they  caused  by  articular  rheumatism,  arthritis 
deformans,  injuries  or  acute,  especially  gonorrheal  in- 
flammation, are  decided  and  convincing.  Active  hyper- 
emia  has  been  employed  fty  means  of  hot  air.  Its  effects 
merit  recognition  in  chronic  rheumatism  and  arthritis 
deformans,  especially  striking  are  here,  like. in  all  diseases 
which  are  favorably  influenced  by  hyperemia,  the  imme- 
diate relief  of  pain  and  increase  of  mobility.  After  a 
somewhat  prolonged  application  one  can  observe  reduc- 
tion of  swelling,  decrease  of  existing  crepitations  and  dis- 
appearance of  abnormal  nodular  swellings.  The  same  re- 
sults, as  I  have  repeatedly  pointed  out,  can  be  obtained 
with  stasis  hyperemia,  but  one  meets  occasionally  with 
greater  difficulties  in  getting  an  intense  stasis  hyperemia 
than  is  the  case  in  tuberculosis. 

Finally,  treatment  with  the  suction  apparatus  must  be 
considered  here.  These,  too,  as  was  to  be  expected,  we 
have  employed  with  good  results  in  arthritis  deformans 
and  chronic  rheumatism.  I  have  found  the  suction  ap- 
paratus especially  useful  in  several  cases  of  gonitis  crepi- 
tans,  in  which  hot  air  had  proved  ineffective. 

It  is  superfluous  to  cite  examples  of  the  favorable  ef- 
fect of  hyperemia  in  these  diseases  for  they  have  been 
so  often  described  and  confirmed  that  they  require  no 
proofs.  I  will  not  omit  to  mention  that  I  have  frequently 
met  cases,  especially  of  chronic  rheumatism,  for  which 
I  have  employed  all  these  remedies  (hot  air,  stasis  hyper- 
emia, suction  apparatus)  one  after  another  without  last- 
ing success.  Almost  without  exception  they  at  first  pro- 
duced subjective  improvement,  reduction  of  pain  and  in- 
crease of  mobility.  Finally  a  standstill  was  reached  and 
no  further  improvement  coming  on,  the  patient  not  in- 
frequently withdraws  from  the  treatment.  As  a  rule, 
however,  the  improvement  can  be  noticed  early  and 
plainly.  Among  all  the  cases  which  I  have  been  able  to 
follow  I  have  observed  but  one  real  cure  and  this  was  a 

214 


TREATMENT   OF   CHRONIC   STIFF  JOINTS  215 

case  in  my  private  practice.  The  cure  was  obtained  prin- 
cipally from  the  use  of  stasis  hyperemia ;  at  the  same  time 
slight  massage  was  employed  but  only  to  the  extent  of 
rubbing  away  the  edema  which  had  developed. 

Better  and  more  complete  cures  than  in  chronic  rheu- 
matism and  arthritis  deformans  I  have  obtained  in  sev- 
eral cases  of  grave  gonorrheal  stiff  joints,  which  fol- 
lowed acute  inflammation.  Among  these  are  two  cases 
which,  in  spite  of  protracted  medico-mechanic  therapy, 
forcible  motion  of  the  stiffened  joints,  massage  and  com- 
presses, had  not  improved  and  were  in  hopeless  condi- 
tion. The  two  gentlemen  concerned  were  agreeably  sur- 
prised at  the  change  in  the  therapy,  as  in  place  of  the 
former  painful  treatment  a  pain-relieving  one  with  better 
results  took  place. 

In  most  cases  where  many  points  were  affected  I  have 
combined  both  methods,  active  and  passive  hyperemia. 
This  is  to  be  recommended  because  the  treatment  of  all 
bodily  joints  with  one  of  the  remedies,  especially  hot  air, 
alone  is  difficult  of  execution.  One  can  also  soon  learn 
from  the  patients  which  of  the  two  agrees  with  them 
more.  I  have  usually  found  that  at  first  they  prefer  hot 
air,  later  on,  however,  the  stasis  hyperemia.  Very  often 
in  these  cases  it  is  hard  to  tell  whether  really  one  or  the 
other  remedy  has  produced  the  greater  improvement ;  for, 
as  I  have  already  remarked,  one  can  frequently  observe 
that  with  the  treatment  by  hyperemia  of  individual  joints 
the  others  improve  at  the  same  time. 

The  treatment  with  hyperemia  is  furthermore  very  suc- 
cessful in  stiff  joints  due  to  trauma,  and  for  these  cases, 
too,  it  can  be  said  that  both  active  and  stasis  hyperemia 
are  equally  efficient.  After  I  had  obtained  good  results 
in  traumatic  stiff  joints  with  the  suction  apparatus,  my 
former  assistant,  staff-surgeon  Dr.  Blecher  (206),  demon- 
strated that  the  ordinary  stasis  hyperemia  by  means  of 
a  bandage  produces  good  results. 

Of  late  Sudeck  has  confirmed  the  observations  made 
by  Blecher.  Sudeck  is  of  the  view  that  stiff  joints  after 
inflammation  and  injury  are  due  to  bone  atrophy  demon- 
strated by  him  as  associated  with  them  and  that  the 
stasis  hyperemia  acts  by  an  increase  of  new  bone  growth. 
This  view  is  very  one-sided,  for  while  it  is  true  that  in 


216  TREATMENT  OF  CHRONIC   STIFF  JOINTS 

those  diseases  the  bones  become  atrophic,  it  is  not  they 
alone  which  suffer,  for  the  soft  parts,  too,  become  atro- 
phic. I  have  mentioned  it  repeatedly  that  the  atrophy  of 
the  soft  parts  improves  under  treatment  by  hyperemia. 
It  is  therefore  arbitrary  to  place  the  atrophy  of  the  bones 
in  the  foreground,  with  the  improvement  of  which  the 
stiffness  becomes  better.  For  I  have  observed  stiff  joints 
of  grave  form  in  which  the  Roentgen  rays  showed 
hypertrophy  and  not  atrophy,  improve  under  treatment 
by  hyperemia,  also  such  which  evidently  concerned  only 
the  soft  parts,  as  in  tendon  and  skin  scars,  caused  by 
panaris.  Furthermore,  I  have  observed,  as  already  men- 
tioned, that  nodular  thickening  of  the  tendons  due  to 
gonorrheal  inflammation  disappears  under  treatment  with 
hyperemia.  I  therefore,  now  as  before,  lay  great  stress 
on  the  solving  effect  of  hyperemia,  which,  as  already  men- 
tioned, we  have  been  able  to  observe  repeatedly.  That 
in  addition  other  factors  are  active  I  have  never  doubted. 

I  have  often  asserted  my  belief  that  serous  infiltration 
and  swelling  of  shrunk  soft  parts  play  a  great  role  and, 
above  all,  the  relief  of  pain  associated  with  hyperemia. 
Otherwise  it  could  not  be  understood  how  stiff  joints, 
after  having  been  rendered  hyperemic  for  one  hour,  be- 
come more  mobile.  That  alongside  of  this  the  purely 
passive  nutrition  of  the  bone  can  play  a  role  I  do  not 
doubt.  But  of  all  things  which  are  considered  this  is  the 
least  proven.  That  atrophies  rapidly  disappear  after  the 
removal  of  the  cause  of  the  disease  is  no  more  astonish- 
ing than  that  they  develop  with  an  incredible  rapidity. 
But  we  know  the  reason  neither  for  one  nor  the  other. 

In  traumatic  stiff  joints  I  have  of  late  made  use  of 
the  suction  apparatus  and  consider  it  for  these  affections 
the  most  prominent  remedy.  While  the  suction  appara- 
tus must  be  used  with  the  greatest  caution  in  infectious 
affections  of  the  joints,  in  traumatic  stiff  joints  it  can  be 
used  boldly.  The  affected  joint  is  exposed  in  the  ap- 
paratus to  a  vigorous  hyperemia  one  to  two  times  daily. 
We  have  never  seen  any  damage  result  from  it  in  these 
affections.  As  a  proof  I  will  describe  several  cases : 

i.  A  laborer,  aged  thirty-five,  sustained  January  i, 
1902,  a  luxation  of  the  left  elbow-joint.  This  was  cor- 
rected by  me  by  the  bloodless  method  twenty-two  days 


TREATMENT  OF  CHRONIC  STIFF  JOINTS  217 

after  the  accident,  and  immediately  afterwards  the  daily 
treatment  with  hot  air  and  massage  was  begun.  Feb- 
ruary 15,  1902,  the  following  status  was  found:  The 
elbow-joint  can  be  flexed  to  an  agle  of  87°  and  extended 
to  125°.  Supination  and  pronation  can  be  executed  to 
a  very  limited  extent. 

February  I5th  treatmerit  with  the  suction  apparatus 
was  commenced,  lasting  every  day  twenty  minutes.  Im- 
mediately afterwards  considerable  subjective  improve- 
ment set  in ;  the  patient  stated  that  the  joint  was  more 
supple.  March  5th  the  forearm  could  be  extended  to  an 
angle  of  135°  and  flexed  to  an  angle  of  70°  and  extended 
to  145°.  Rotation  was  entirely  free  and  the  joint  well 
movable  and  functionating.  Very  striking  was  the  rapid 
diminution  of  the  swelling  under  the  treatment  with  the 
suction  apparatus.  For  an  old  luxation  this  seems  to 
me  an  excellent  result. 

2.  A  fifteen-year-old  boy  was  attacked  in  December, 
1901,  by  a  panaris  of  the  dorsum  of  the  right  hand,  which 
was  split  outwardly.  Over  the  third  metacarpus  was  a 
scar  adherent  to  the  bone.  The  bone  felt  thickened  and 
so  appeared  in  the  Roentgen  picture.  All  fingers  of  the 
hand,  except  the  small  one,  the  last  two  joints  of  which 
could  be  moved,  were  stiff,  which  was  due  to  an  im- 
mobilizing dressing  worn  continuously.  This  stiffness 
was  especially  pronounced  in  the  phalango-metacarpal 
joints.  These  joints  could  not  be  moved  with  the  great- 
est force.  The  hand  was  treated  in  the  suction  appara- 
tus half  an  hour  twice  daily  from  February  I3th  to 
March  I4th,  1902.  All  fingers,  except  the  middle  one, 
became  entirely  mobile  and  could  be  bent  into  a  fist. 
The  middle  finger  did  not  keep  pace  and  the  Roentgen 
picture  shows  that  there  exists  a  bony  obstacle  in  its 
phalango-metacarpal  joint. 

It  seems  to  me  that  this  case,  too,  can  be  considered  an 
excellent  success.  At  least,  I  used  to  try  in  vain  to  re- 
store the  mobility  in  just  such  fingers  which  became  stiff 
in  the  phalango-metacarpal  joint  by  inflammation  and 
prolonged  bandaging.  Even  forcible  motions  under 
anesthesia  do  not  suffice ;  if  the  latter,  however,  are  car- 
ried to  excess  it  may  come  to  full  luxations. 

As  already  mentioned,  both  forms  of  hyperemia  loosen 


218 

stiff  joints,  but,  as  in  passive  hyperemia  by  a  bandage, 
while  this  is  on,  absorption  is  retarded,  I  have  kneaded 
away  the  edema  in  chronic  articular  rheumatism,  which 
has  been  treated  with  stasis  hyperemia  for  some  time, 
once  or  twice  daily,  and  Blecher  recommends  the  addi- 
tion of  massage  for  traumatically  stiffened  joints  which 
have  been  treated  with  stasis  hyperemia  by  a  bandage. 

I  will  now  briefly  recapitulate  the  technic  of  the  treat- 
ment of  stiff  joints  with  hyperemia:  I.  Hot  air  is  to 
be  applied  one  hour  daily  according  to  rules  laid  down 
in  the  general  part.  2,.  The  suction  apparatus  is  used 
one  to  two  times  daily  for  from  twenty  to  thirty  minutes. 
3.  Stasis  hyperemia  with  the  bandage  is  employed  from 
eight  to  twenty-two  hours  daily.  In  the  interval  the 
limb  is  to  be  postured  high  and  the  developed  edema 
massaged  away  once  or  twice  daily.  All  that  is  needed 
is  a  kneading  away  of  the  edema ;  scientific  massage  is 
not  essential. 

In  all  treatments  with  hyperemia  which  must  be  con- 
tinued for  months  .and  years,  as  is  sometimes  necessary 
in  joints  afflicted  with  chronic  rheumatism  and  arthritis 
demormans,  it  is  advisable  to  occasionally  desist  from 
treatment  for  a  week,  a  month,  or  even  longer. 

I  consider  the  treatment  of  stiff  joints  with  hyperemia 
as  extremely  important,  for,  with  due  respect  to  the  re- 
sults achieved  by  mechano-therapy,  as  practiced  in  spe- 
cial mechano-therapeutic  institutes  to  which  such  cases 
nowadays  apply  for  treatment,  I  have  never  been  able 
to  free  myself  from  the  conviction  that  we  have  here  a 
case  of  fashion  overdone.  Very  frequently  we  see  cases 
which  have  become  worse  instead  of  better  by  mechano- 
therapy,  for  the  strongly  irritating  treatment  produces 
inflammatory  processes  in  the  chronic  stiff  joints.  Be- 
sides, the  treatment  is  by  no  means  pleasant  to  the  pa- 
tient and,  what  must  also  be  considered  as  of  no  small 
importance,  the  treatment  can  be  had  at  certain  insti- 
tutes only.  Therefore,  I  believe  that  a  method  which  is 
at  the  disposal  of  every  physician  and  which  yields  at 
least  the  same  results  has  a  great  value.  From  a  large 
experience  I  have  come  to  the  conviction  that  if  two  in- 
stitutions would  be  opened,  in  one  of  which  mechano- 
therapy  only  were  practiced,  while  in  the  other  treat- 


TREATMENT  OF   CHRONIC   STIFF  JOINTS  219 

ment  with  hyperemia  exclusively  were  used  for  equally 
grave  cases  of  stiff  joints,  the  latter  would  soon  get  the 
upper  hand.  I  am  not  so  one-sided  as  to  assert  that 
mechano-therapy  is  without  value  or  that  it  could  not 
usefully  be  combined  with  the  treatment  by  hyperemia. 
An  important  feature  of  the  latter  is  that  the  patients 
themselves  soon  become  familiar  with  it  and.  are  able  to 
continue  it  at  home,  for  frequently  these  diseases  are  so 
chronic  that  a  complete  course  of  treatment  in  the  hos- 
pital is  impossible.  [The  author  adds  that  for  this  reason 
his  hot-air  boxes  are  the  most  important  because  they 
are  durable  and  cheap  and  therefore  within  reach  of  even 
poor  patients.  A  very  good  Betz  apparatus  can  now  be 
obtained  for  a  few  dollars.  Should,  however,  the  patient 
be  so  poor  that  he  can  not  get  an  apparatus  himself,  an 
arrangement  for  a  loan  of  one  from  his  physician  has 
proven  a  good  way  of  controlling  a  case  by  the  attending 
physician. — Ed,] 


CHAPTER  XXII 

HYPEREMIA  AS  AN  ABSORPTIVE  AGENT 

I  have  demonstrated  that  active  hyperemia  is  one  of 
the  most  powerful  agents  for  the  promotion  of  absorp- 
tion. For  this  reason  I  have  used  it  extensively  for  the 
absorption  of  edema  and  especially  as  after-treatment  of 
bone  fractures,  in  which,  as  is  known,  edema  usually  de- 
velops on  rising,  after  the  fracture  has  healed.  But  in  all 
other  forms  of  local  edema,  as  long  as  acute  inflammation 
did  not  develop  with  them,  I  have  successfully  employed 
active  hyperemia.  I  have  also  derived  great  benefit  from 
its  use  in  fully  developed  forms  of  elephantiasis.  The 
following  case  may  serve  to  illustrate  its  effect  :- 

A  woman,  aged  twenty-eight,  noticed  eighteen  years 
ago  that  a  swelling  appeared  on  the  external  malleolus 
of  the  left  foot,  which  gradually  became  enlarged  and 
spread  after  several  deliveries.  She  was  admitted  July  3. 
1900,  with  an  enormous  elephantiasis  of  the  entire  left 
extremity  and  incipient  elephantiasis  of  the  right  leg. 
The  left  extremity  was  treated  daily  for  one  hour  from 
July  4th  to  the  28th  with  a  hot-air  apparatus  which  took 
in  the  entire  limb.  The  following  measurements  will 
give  you  an  idea  how  thick  the  limb  was  and  how  effect- 
ive the  hot-air  treatment  proved. 

The  circumference  of  the  limb  was: 

July  3d.  July  28th.  Decrease. 

Below   inguinal   bend 67.5cm.  56.0cm.  11.5cm. 

Middle  of  thigh 67.0  cm.  60.0  cm.  7.0  cm. 

Above    patella 67.5  cm.  -51.0  cm.  15.5  cm. 

Below    patella 53.0cm.  42.0cm.  11.0cm. 

Middle  of  leg •....:..  49.5  cm.  42.0  cm.  7.0  cm. 

Malleoli   34.0  cm.  29.5  cm.  4.5  cm. 

Lisfranc's    joint 28.5cm.  25.5cm.  3.0cm. 

During  the  treatment  the  woman  lost  9^2  pounds.  The 
limb,  as  compared  with  its  appearance  before  treatment, 
could  hardly  be  recognized.  The  patient  was  given  a 
hot-air  apparatus  for  use  at  home.  Whether  she  has 
used  it  and  with  what  success  is  not  known. 

The  active  hyperemia  by  hot  air  has  further  been 
employed  for  the  absorption  of  effusions  of  the  joints. 

220 


HYPEREMIA   AS   AN    ABSORPTIVE   AGENT  221 

My  assistant,  Dr.  Klapp  (207),  and  Dr.  Schaffer  (208) 
have  reported  the  observations  made  in  the  local  clinic. 
We  have  so  far  treated  about  sixty  cases  with  hot  air 
and  with  very  satisfactory  results.  To  be  sure,  one  does 
not  always  succeed  in  causing  the  effusion  of  joints  to 
disappear  or  in  preventing  its  return,  nevertheless,  I 
consider  the  remedy  one  of  the  best,  if  not  the  best,  we 
have.  The  great  advantage  of  the  treatment  is  in  this, 
that  the  affected  joint  is  not  fixed  and  that  the  patient 
is  permitted  to  make  motions  with  it.  Indeed,  we  have 
been  successful  in  the  ambulatory  treatment  of  several 
cases  of  chronic  hydrops  genu.  The  avoidance  of  im- 
mobilization seems  to  possess  a  great  advantage,  for  one 
frequently  sees  the  return  of  effusion  which  had  disap- 
peared in  fixed  joints,  when  the  patient  rises  and  moves 
about.  True,  even  this  remedy  fails  occasionally,  of 
which  I  was  convinced  but  recently.  A  young  gentleman 
had  a  chronic  hydrops  which  quickly  disappeared  after 
application  of  hot  air  and  rest  in  bed,  but  reappeared  on 
rising. 

Bloody  effusions,  just  as  watery  ones,  can  be  success- 
fully treated  with  active  hyperemia.  The  injured  has 
subjectively  a  pleasant  sensation  from  the  remedy.  We 
see  here,  like  in  all  other  cases  in  which  treatment  by 
hyperemia  is  effective,  that  the  rapid  disappearance  of 
the  pain  and  symptoms  is  always  the  most  prominent  and 
first  sign. 

We  have  also  treated  with  hot  air  a  series  of  cases 
of  blood  effusion  into  the  soft  parts.  The  very  nature  of 
the  affection  does  not  permit  us  to  say  whether  this 
method  has  been  of  great  use  or  not.  Taken  all  in  all,  I 
am  decidedly  under  the  impression  that  it  is  about  as  ef- 
fective as  massage. 

Wherever  we  wish  to  unfold  vigorous  absorption  the 
active  hyperemia  which  is  produced  by  hot  air  stands 
in  the  foreground ;  it  is  to  be  employed  daily  for  one 
hour,  or  at  most  two  hours.  In  the  latter  case  the  af- 
fected limb  is  to  be  exposed  to  the  remedy  morning  and 
and  evening  an  hour  at  a  time.  Passive  hyperemia  by 
means  of  a  stasis  bandage  need  scarcely  be  considered 
here,  though  we  have  used  it  frequently  with  good  re- 
sults in  combination  with  massage  for  effusion  of  blood. 


222       HYPEREMIA  AS  AN  ABSORPTIVE  AGENT 

But  here  we  have  to  deal  more  with  a  dissolving  than  an 
absorbing  effect  and  the  latter  is  accomplished  essential- 
ly by  massage.  On  the  other  hand,  I  have  great  confi- 
dence in  the  suction  apparatus  for  such  cases,  especially 
when  it  is  so  employed  that  the  affected  part  is  rendered 
hyperemic  by  a  few  movements  with  the  piston,  air  being 
permitted  to  enter  immediately  afterwards,  and  this  pro- 
cedure is  often  repeated.  We  have  used  the  apparatus 
for  this  purpose  several  times,  but  our  experience  is  so 
limited  that  I  can  pass  no  opinion  on  its  efficacy.  '  The 
arrangement  of  Junod's  boot  with  which  attenuated  and 
condensed  air  can  be  applied  alternately,  seems  worthy 
of  a  trial  in  such  cases.  This  seems  especially  indicated 
in  joint  effusion  where  we  first  render  hyperemic  the  dis- 
eased part  and  then  exercise  a  powerful  pressure  over  it. 
We  could  combine  the  absorbing  effect  of  hyperemia  with 
the  tried  Volkmann  compression,  for  it  is  doubtful1 
whether  there  exists  an  agent  for  compression  which  has 
a  stronger  and  at  the  same  time  less  harmful  effect  than 
evenly  compressed  air. 


CHAPTER  XXIII 

TREATMENT    OF    NEURALGIAS    AND    OTHER 
PAINS    BY    HYPEREMIA 

In  several  places  in  this  book  I  have  plainly  shown 
that  of  all  effects  exercised  by  hyperemia  the  pain-reliev-1 
ing  one  is  the  most  striking.  It  has  also  proved  itself 
very  effective  in  various  painful  affections  without 
demonstrable  anatomical  changes,  especially  in  neural- 
gias. For  the  latter  active  hyperemia  is  evidently  the 
far  better  remedy.  I  have  used  it,  as  did  many  other 
physicians,  with  good  results  in  numerous  cases  of  lum- 
bago and  sciatica  and  a  few  cases  of  trigeminus  neuralgia. 
It  is  self-evident  that  in  lumbago  the  pelvic  and  lumbar 


Fig.  11, 

regions  are  to  be  treated,  but  even  in  sciatica  I  find  il 
more  useful  to  treat  the  affected  region  with  the  special 
attachment  for  the  hot-air  apparatus  than  the  subjection 
of  the  entire  limb  up  to  the  hip  to  hot  air. 

Trigeminus  neuralgia  was  treated  by  us  in  a  very 
simple  manner.  We  permitted  the  hot  air,  as  it  came 
from  the  chimney,  to  flow  against  the  diseased  face,  or 
we  fastened  a  wooden  attachment  to  the  chimney  and 
held  one  end,  shaped  like  a  funnel,  10  cm.  from  the  skin. 

[A   similar   arrangement    could    be   utilized    with    the 

223 


224      TREATMENT  OF  NEURALGIAS  BY  HYPEREMIA 

Betz  apparatus  by  inserting  a  tin  pipe  into  the  top  open- 
ing intended  for  ventilation.  Hopkins  hot-air  apparatus 
(see  Fig.  n)  will  prove  more  convenient  and  the  current 
of  hot  air  can  be  thrown  directly  on  the  skin. — Ed.] 

I  have  treated  only  a  few  cases  of  trigeminus  neuralgia 
(altogether  eight)  with  hot  air,  among  which  six  were 
of  a  grave  form  which  had  previously  been  treated  in 
vain  with  all  possible  remedies.  Of  these  eight  cases, 
five  have  been  cured  by  this  agent  and  three  have  not 
been  cured.  In  two  of  the  latter  I  had  to  perform  re- 
section of  the  nerves.  I  have  also  employed  against 
trigeminus  neuralgia  stasis  hyperemia,  which  I  produced 
by  the  application  of  a  rubber  bandage  around  the  neck, 
but  had  no  result  with  it.  In  two  cases  in  which  the 
stasis  hyperemia  failed,  I  succeeded  with  active  hyper- 
emia produced  by  hot  air. 

On  the  other  hand,  I  have  successfully  employed  stasis 
hyperemia  against  all  sorts  of  headache,  especially  anemic 
headaches,  and  the  successes  which  we  have  achieved 
have  been  confirmed  in  other  quarters.  It  also  has  a 
favorable  effect  on  headaches  from  other  causes,  even 
in  that  produced  by  meningitis ;  for  these  we  have  em- 
ployed it  several  times  successfully  to  the  extent  that  the 
patients  complained  less.  In  two  cases  of  chorea,  the 
remedy  acted  favorably ;  in  one  it  produced  an  astonish- 
ing result.  I  have  also  tried  stasis  hyperemia  on  the 
head  for  epilepsy  but  could  not  observe  a  marked  suc- 
cess. 

The  technic  of  stasis  of  the  head  is  very  simple.  Apply 
a  rubber  bandage  or,  better  still,  an  elastic  bandage  one 
side  of  which  has  hooks,  the  several  eyes  successively 
arranged  in  rows,  so  firmly  around  the  neck  that  a  per- 
ceptible hyperemia  occurs  in  the  skin  of  the  face.  Here,) 
as  elsewhere,  the  rule  must  be  observed  that  the  hyper- 
emia must  never  aggravate  but,  on  the  contrary,  dimin- 
ish the  symptoms.  As  soon  as  the  patient  begins  to 
complain,  either  the  bandage  is  too  firmly  applied  or  the' 
case  is  not  "suitable  for  this  treatment.  I  have  given  a 
detailed  description  of  this  method  in  an  earlier  contribu- 
tion (209).  I  suspect  that  the  better  effect  of  the  active 
form  of  hyperemia  in  neuralgias  is  due  principally  to  in- 
creased absorption. 


CHAPTER  XXIV 

USE   OF   HOT   AIR   IN   DISEASES   OF   THE 
BLOOD-VESSELS 

An  old  quarrel  turns  around  the  question  whether  the 
dilatation  of  the  vessels  which  occurs  after  artificial 
bloodlessness,  heat  and  similar  effects  is  to  be  inter- 
preted as  a  paralysis  or  irritation  of  the  vessel  nerves 
respectively  vessels.  As  regards  the  reaction  hyper- 
emia  of  artificial  bloodlessness,  about  which  the  former 
was  the  prevailing  undisputed  view,  I  believe  that  I 
have  convincingly  proved  (210)  that  there  can  be  no 
question  of  a  paralysis.  By  analogy  I  conclude  that  the 
same  is  the  case  after  heat  effects,  as  long  as  we  have  no 
burns.  If  this  dilatation  by  heat  is  an  active  process 
we  have  in  it  a  remedy  to  exert  a  powerful  stimulus  on 
the  vessels  not  unlike  the  effect  by  intense  cold.  This 
happens  in  a  large  number  of  hydrotherapeutic  measures. 
But  I  believe  that  the  effect  of  intense  hot  air  in  this 
branch  is  more  effective  than  any  other  form  of  heat.  I 
have  frequently  observed  that  in  the  circulatory  dis- 
turbances of  old  fractures  the  edema  and  the  lividity  of 
the  skin  disappear  much  faster  after  it  than  any  other 
remedy.  The  same 'holds  good  for  a  peculiar  and  dis- 
agreeable vascular  disease,  which  is  prevalent  in  Pom- 
erania,  leading  to  leg  ulcers  and  eczema  and  counted 
among  the  varicose  affections.  The  large  veins  in  these 
cases  are  but  little  dilated  but  on  standing  there  imme- 
diately appears  a  pronounced  lividity  and  venous  stasis 
in  the  skin  of  the  leg,  which  again  produce  all  the  known 
phenomena  preceding  grave  varices.  Probably  we  have 
to  deal  with  an  affection  of  the  small  veins  and  perhaps 
also  of  the  capillaries.  [The  method  of  treatment  for 
varicose  veins  consisting  in  the  strapping  of  the  affected 
area  by  means  of  adhesive  plaster  strips  has  produced 
favorable  results  which  undoubtedly  are  solely  due  to 
hyperemia.  In  one  instance  the  patient,  a  woman  of 
about  fifty,  could  not  tolerate  the  treatment  because  the 
straps  irritated  her  skin.  I  suggested  hot  air  and  after 
ten  treatments  a  small  varicose  ulcer  which  bothered  her 
considerably  had  entirely  disappeared  and  the  general 

15  '  225 


226          USE  OF  HOT  AIR   IN   BLOOD-VESSEL  DISEASES 

tone  of  the  vein  was  improved.  In  four  other  cases  the 
results  were  promising  in  the  beginning,  but  the  patients 
did  not  continue  the  treatment  long  enough,  preferring  to 
wear  elastic  stockings. — Ed.] 

Even  in  these  stubborn  cases  hot  air  has  repeatedly 
rendered  us  excellent  service.  Perhaps  the  addition  of 
a  cold  douche,  applied  to  the  bright  red  limb  immediately 
after  its  removal  from  the  hot-air  apparatus,  has  a  still 
better  effect.  As  is  well  known  from  hydrotherapy  it 
is  the  rapid  change  between  cold  and  warm  which  stimu- 
lates the  vessels.  At  any  rate,  it  seems  to  me  that  hot 
air  is  one  of  the  most  important  agents  with  which  to 
exercise  diseased  and  inactive  vessels  (a  sort  of  gym- 
nastics of  the  vessels).  Nor  do  we  need  to  limit  our- 
selves to  the  consideration  of  the  arteries  and  veins.  I 
believe  I  have  demonstrated  in  my  contribution  on  the 
development  of  collateral  circulation  that  in  the  hyper- 
emia  produced  by  the  dilatation  of  the  vessels  the  capil- 
laries play  a  prominently  active  role.  In  this  case  the 
hot  air  is  to  be  employed  one  hour  daily. 

At  the  first  glance  one  could  assume  that  the  favor- 
able effect  of  hot  air  on  frost-bite,  which  Ritter  has  estab- 
lished, is  due  to  the  exercise  and  strengthening  of  the 
apparently  paralyzed  vessels ;  but  this  view  falls  flat,  for 
Ritter  proved  that  the  stasis  hyperemia,  too,  is  effective 
in  such  cases.  Ritter's  view  that  we  have  here  to  deal 
with  a  stimulation  of  the  regeneration  of  the  injured 
cells  is  probably  correct. 


CONCLUSION. 


I  hope  that  I  have  succeeded  in  sketching  the  outlines 
of  a  doctrine  of  the  effect  and  application  of  hyperemia 
on  as  scientific  a  basis  as  that  of  any  other  of  our  thera- 
peutic methods  with  the  advantage  of  being  simple  and 
logical.  It  seems  to  me  that  I  have  presented  views  and 
observations  sufficiently  ripe,  for  I  have  practiced  these 
methods  for  more  than  eleven  years  and  as  I  have  so 
far  treated  with  hyperemia  over  a  thousand  cases,  most 
of  my  assertions  are  based  on  unusually  rich  observation. 
I  have  intentionally  avoided  reporting  experiments  in 
other  directions  than  those  described,  which  have  not  led 
to  definite  results.  It  is  for  this  reason  that  many  dis- 
eases, besides  those  described,  for  which  I  have  em- 
ployed hyperemia,  have  been  mentioned  either  super- 
ficially or  not  at  all. 

[In  a  private  letter  to  the  editor  the  author  regrets 
that  he  has  been  unable  to  incorporate  in  his  book  the 
favorable  results  obtained  with  hyperemia  i'n  cases  ol 
teno-vaginitis  and  promises  to  publish  them  in  another 
edition  which,  however,  will  not  appear  for  some  time.— — 
Ed.] 

But  I  am  convinced  that  a  remedy  which  nature  uses 
so  extensively  for  the  removal  of  all  possible  injuries 
permits  of  a  still  wider  application. 


227 


BIBLIOGRAPHIC    REFERENCES 


1.  Sprengel,   Zweckmassigkeit  tind  Anpassung.     Akad.  Rede., 
Giessen,   1898,  and  Ziegler,  Ueber  den  derzeitigen  Stand  der  Dar- 
winschen    Lehre.     Jena,    1902. 

2.  J.    Hunter,  Versuche  iiber  das   Blut,  die   Entzundung  und 
die   Schusswunden.      Deutsch    von    Hebenstreit,     Leipsic,     1797, 
Vol.   II,    Part    i.   Chapter  14. 

3.  Neumann,   Ueber  den    Entziindungsbegriff.     Ziegler's   Bei- 
trage    zur    pathologischen    Anatomic    und    zur    allgemeinen    Anato- 
mic, Vol.  5,  p.  348. 

4.  Leber,   Die   Entstehung  der  Entzundung.     Leipsic,   1891. 

5.  Neumann,  1.  c. 

6.  Marchand,    Ueber   den    Wechsel    der   Anschauungen   in   der 
Pathologic.      Antrittsrede    in    Giessen.      Stuttgart,     1882. — Ueber 
die   natiirlichen    Schutzmittel   des   Organismus.     Leipsic,    1900. 

7.  Buchner,   Eine  neue  Theorie  iiber  Erzielung  von  Immuni- 
tat.     Fortschritte  der  Medizin,   1883,   No.  6. — Naturliche   Schutz- 
einrichtungen    des    Organismus.       Miinchener     med.       Wochen- 
schrift.    1899,    Nos.   39  and  40. 

8.  Metschnikoff,   Legons  sur  la  pathologic  comparee  de  1'in- 
flammation.      Paris,    1892. 

9.  Pfliiger,  Die  teleologische  Mechanik  der  lebendigen  Natur. 
Bonn,    1877. 

10.  S.   Bier,   Entstehung  des   Collateral  kreislaufes.     Virchow's 
Archiv,   Vol.    147,   p.  256. 

n.     Bier,      Heilwirkung     der     Hyperamie.       Miinchner     med. 
Wochenschrift,    1897.    No.    32. 

12.  Ueber  die  wichtigsten  ortlichen  und  Allgemeinwirkungen 
der  cutanen  Revulsion  auf  die  Zirkulation  von  Francois  Franck. 
From   the   Gazette  hebdomadaire  translated  into    German  by  T. 
Fodor,  Blatter  fur  klinische  Hydrotherapie.  Vol.  II,  No.  n,  1892. 

13.  Compare    Braam    Houckgeest,    Pfluger's    Archiv,   Vol.    6. 

14.  Klapp,    Ueber    die    Behandlung    yon    Gelenkergiissen    mit 
heisser  Luft.     Munchener  med.  W.,   1000,   No.  23. 

15.  Sarah  Amitin,  Ueber  den  Tonus  der  Blutgefasse  bei  Ein- 
wirkung  der  Warme  und  Kalte.     Zeitschrift  fur  Biologic,   Vol.  35. 
New  series.  Vol.  17,  p.  13. 

16.  Lewaschew,  Ueber  das  Verhalten  der  peripherischen  vaso- 
motorischen  Centren  zur  Temperatur.     Pfluger's  Archiv,  Vol.  26, 
p.  60. 

17.  Bier,  Virchow's  Archiv,  Vol.   147,  p.  270. 

18.  Pietrowski,  Studien  iiber  den  peripheren  Gefassmechanis- 
mus.     Pfluger's  Archiv,  Vol.   55,  p.   240. 

19.  Bier,  Ueber  die  wahrend  und  nach  der  kiinstlichen  Blut- 
leere   auftretenden    Gefassveranderungen   und   ihre  physiologische 
Erklarung.     Deutsche  med.   Wochenschrift,    1899,  No.  31. 

20.  Goltz    and    Ewald,    Der    Hund    mit    verkiirztem    Riicken- 
mark.     Pfluger's   Archiv,  Vol.  63,  p.  362. 

21.  Ettore  Balli,  Ueber  den  Einfluss  lokaler  und  allgemeiner 

229 


230  BIBLIOGRAPHIC   REFERENCES 

Erwarmung  und  Abkiihlung  der  Haul  auf  das  menschliche  Flam- 
mentachygramm.      Inaugural-Dissertation,     Bern,     1896. 

22.  Mendelsohn,    Ueber  die   therapeutische  Verwendung  sehr 
holier  Temperaturen.     Verh.    d.    16.   Kongresses   fiir   innere    Medi- 
zin,  1898. 

23.  Krause,     Erfahrungen    iiber    therapeutische    Verwendung 
iiberhitzter   Luft.     Verh.   d.   deutschen   Gesellschaft  fiir  Chirurgie, 
1899,   18.   Kongress  II,  p.  230. 

24.  Schreiber,   Ueber   Heissluftapparate  und   Heissluftbehand- 
lung.     Zeitschr.  fiir  dietatische  und  physikalische  Therapie,  Vol. 
5,  Brochure  2. 

25.  Walsh,   Hot-air  Treatment  of  Eczematous,   Gouty,   Rheu- 
matic  and    Other  Affections.     The    Lancet,    1900,   p.   482. 

26.  Bier,    v.    Esmarch's    Festschrift,   p.   63.    Kiel   and    Leipsic, 
1893. — Munch,  med.  W.,  1899,  Nos.  48  and  49. — Therapie  der  Ge- 
genwart,  February,  1902. 

27.  Clado;    Bericht    des     franzosischen     Chirurgenkongresses 
vom  Jahre,  1891. 

28.  Krause,  Die  ortliche  Anwendung  iiberhitzter  Luft.  Munch, 
med.  W.,   1898,  No.   18,  and   Erfahrungen  iiber  die  therapeutische 
Verwendung  iiberhitzter  Luft.    Verh.  der  deutschen  Ges.  f.  Chir- 
urgie,  i8th  congress,  Vol.  II,  p.  225,  1899. 

29.  Wilson,   Hot  Air  in  Joint  Diseases.     Annals  of  Surgery, 
1809,  p.   155. 

30.  Reitler,    Die    Trocken-Heissluftbehandlung.      Baden    near 
Vienna,   1900.      Published  by  A.   Dittrich. 

31.  Roth.    Eine    neue    Heissluftapparat    Konstruktion.      Zeit- 
schrift  f.  dietatische  und  physikalische  Therapie,  Vol.  6,  Brochure 
3,   1902. 

32.  Bier,    Ueber   praktische    Anwendung    kunstlich    erzeugter 
Hyperamie.     Therapie  der  Gegenwart,  February,  1902. 

33.  v.   Esmarch's  Festschrift,  p.  63.  Kiel  and  Leipsic.  1893. 

34.  Bier,  Ueber  verschiedene  Methoden  kiinstliche  Hyperamie 
zu   Heilzwecken  hervorzurufe*n.     Miinch.  med.   W.,  1899.   Nos.  48 
and  49,  and   "Therapie   der   Gegenwart,"    February,    1002. 

35.  According   to    v.    Piibram.    Chronischer    Gelenkrheumatis- 
mus,    etc.,    in    Nothnagel's    specieller    Pathologic    und    Therapie. 
Vienna,    1902. 

36.  Several   contributions    on   the    same    subject:    Frey,   Vor- 
trag  auf  der  21.  Versammlung  der  Balneolog.  Ges.  zu  Frankfurt. 
March,  T9OO. — Deutsche    Medizinalzeitung,    1900,    No.    35. — Ueber 
Behandlung    mit    der    Luftdusche.      Therapeutische    Monatshefte, 
June,    1900. — Ueber   die    Behandlung,  von     Neuralgien     mit     der 
Heissluftdusche.     Archiv   fiir   Psychiatric,   Vol.   33,   Brochure  2.— 
Die    Massage   unter    der    heissen     Luftdusche.     Deutsche     med. 
Wochenschrift,   1900,    No.  5. 

37.  On  the  treatment   of  neuralgia   and  rheumatism  by   cur- 
rents of  hot  air,  with  some  account  of  the  apparatus  employed. 
The   Lancet,   November,   1898. 

38.  v.  Lesser,  Ueber  die  Todesursachen  nach  Verbrennungen. 
Virchow's  Archiv,  Vol.  79,  p.  248. 


BIBLIOGRAPHIC   REFERENCES  231 

39.  Ocuvres    completes    d'Ambroise    Pare.      Edition    of    Mal- 
gaigne,  Vol.  II,   L.   XIII,   Chapter  30. 

40.  Nicoladoni,    v.    Dumreicher's    Methode    zur    Behandlung 
drohender    Pseudarthrosen.      Wiener    med.    W.,    1875,    Nos.    5,    6 
and  7. 

41.  Bruns,    Die   Lehre   von   den   Knochenbriichen.     Deutsche 
Chirurgie,   Brochure  27,   1886,   p.  597. 

42.  Thomas,    Contributions   to    Surgery    and    Medicine,    Part 
VI.    The  principles  of  the  treatment  of  fractures  and  dislocations. 
London.    1886. 

43.  Helferich,    Ueber    kiinstliche    Vermehrung   der   Knochen- 
bildung.      Verh.    der  deutschen    Gesellschaft   fur   Chirurgie,    1887,, 
Vol.  2,  p.  249,  and  Archiv  fur  klinische  Chirurgie,  1887,  Vol.  36, 
P-  873- 

44.  Anspitz,    Ueber   venose    Stauung   in   der    Haut.     Viertel- 
jahrsschrift  fur  Dermatologie  und  Syphilis,  1874,  I.  P-  27S- 

45.  Virchow's  Archiv,  Vol.  153,  pp.  311  and  312. 

46.  Landois,    Lehrbuch    der    Physiologic,    loth    edition,    1899, 
pp.   26  and  27. 

47.  Landois,    Die  Transfusion   des   Blutes.      Leipsic,    1875. 

48.  E.  Grawitz,  Klinische  Pathologic  des  Blutes,  p.  211. 

49.  Chvostek,  Ueber  das  Wesen  der  paroxysmalen  Hamoglo- 
binurie. 

50.  Johnson,    Temporary    Albuminuria    the    Result     of     Cold 
Bathing.     British    Med.    Journ.,    1875. — Winternitz,   Die   Hydrothe- 
rapie,   2nd    edition,    Vienna   and    Leipsic,    1890,    p.   83. 

"51.  Reineboth,  Experimentelle  Untersuchungen  iiber  den  Ent- 
stehungsmodus  der  Sugillationen  der  Pleura  infolge  von  Abkiih- 
lung,  etc.  Deutsches  Archiv  f.  klinische  Med.,  Vol.  62,  p.  63,  and 
Centralbl.  f.  innere  Medizin,  1900,  No.  3. 

52.  Reineboth  and  Kohlhardt,  Blutveranderungen  infolge  von 
Abkuhlung.     Ebenda,  Vol.  65,  p.  192. 

53.  Grawitz,    Centralbl.   f.   innere   Medizin,   1899,   No.   46,   and 
1900.  No.  3. 

54.  Junod,  Recherches  physiolcgiques  et  therapeutiques  sur  les 
effets  de  la  compression  et  de  la  rarefaction  de  1'air,  tant  sur  le 
corps  que  sur  les  membres  isoles.     Revue  med.  franc.,  et  etrang, 
1834,  Vol.  in. 

55.  Junod,  Note  sur  un  nouvel  appareil  dit  grande  ventouse 
propre  a  faire  le  vide  sur  la  moitie  inferieure  du  corps,  etc.     Gaz. 
med.  de  Paris,  1838,  Vol.  6,  No.  25. 

56.  Junod,   Nouvelles  observations  sur  l'emploi  des  appareils 
hemospasiques  et  des  bains  d'air  comprime,  lues  a  1'academie  des 
sciences.     Paris,   1843. 

57.  Ficinus,    Die   Hamospasie,    Geschichte,   Beschreibung  und 
Wirkungen  der  grossen  Ventousen  Junods  oder  des  Schropfstie- 
fels.     Leipsic,  1848. 

58.  Junod,   Methode  hemospasique.     Paris  G.   Bailliere,   1843. 

59.  Erpenbeck.  Vorschlag  eines  neuen  Mittels  zur  Regulierung 
des  Blutlaufs  zur  Tilgung  und  Bewirkung  von  Kongestionen,  so- 
wie  zur  Ergiebigkeit  des  Aderlasses.     Caspars  Wochenschrift  fu» 
die  gesammte  Heilkunde,  1838,  p.  373. 


232  BIBLIOGRAPHIC   REFERENCES 

60.  Erpenbeck,    Die   kiinstliche    Luftverdiinnung  als    Heil-   u. 
Hiilfsmittel  bei  mancherlei  inneren  u.  ausseren  Krankheiten.  Hol- 
schers  Hannover'sche  Annalen,  Vol.  4,  Brochure  3. 

61.  Bartels,   Die   Medizin  der  Naturvolker.     Leipsic,  1893,   p. 
124. 

62.  Naumann,  Untersuchungen  iiber  die  physiologischen  Wir- 
kungen   der    Hautreizmittel    (Epispastica).       Prager    Vierteljahr- 
schrift  fiir  die  praktische  Heilkunde,  Vol.  20,  1863,  p.  i. 

63.  Naumann,  Prager  Vierteljahrschrift,  1867,  and  Zur  Lehre 
von  den  Reflexreizen  und  deren  Wirkung.     Pfliiger's  Archiv,  Vol. 
5,  1872. 

64.  Schiiller.     Ueber  die  Einwirkung  einiger  Arzneimittel  auf 
die  Gehirngefasse.     Berliner  klinische  W.,  1874,  p.  294. 

65.  Schiiller,  Experimentalstudien  iiber  die  Veranderungen  der 
Hirngefasse   unter    dem    Einflusse   ausserer    Wasserapplikationen. 
Deutsches  Archiv  fiir  klinische  Medizin,  Vol.  14,  1874,  p.  66. 

66.  Winternitz,    Die    Hydrotherapie    auf    physiologischer   und 
klinischer  Grundlage,  2nd  edition,  Vol.  i,  pp.  109-116. 

67.  Matthes,   Lehrbuch  der   klinischen    Hydrotherapie.     Jena, 
1900,  p.  31. 

68.  Samuel,  Zur  Antipphlogose.     Virchow's  Archiv,  Vol.   127, 
P.  457- 

69.  Zulzer,  Ueber  die  Wirkung  der  ableitenden  Mittel  (Deri- 
vantia).     Deutsche  Klinik,  Vol.  17,  1865,  p.  127. 

70.  Schiiller,   Ueber  die   Einwirkung  einiger  Arzneimittel  auf 
die  Gehirngefasse.     Berliner  klinische  W.,  1874,  p.  294. 

71.  Schede,    Ueber   die  feineren   Vorgange   nach   Anwendung 
starker  Hautreize,  besonders  der  Jodtinktur.     Archiv  f.  klinische 
Chirurgie,  Vol.  15,  1873. 

72.  Wechsberg,  Ueber  den  Einfluss  chemischer  Gegenreize  auf 
Entziindungen.     Zeitschrift  f.  klinische  Medizin,  Vol.  37,  p.  360. 

73.  Samuel,    Entziindungsherd     und     Entziindungshof.       Vir- 
chow's  Archiv,  Vol.    121,    Brochure  2. 

74.  Buchner,  Natiirliche  Schutzeinrichtungen  des  Organismus 
und  deren  Beeinflussung  zum  Zweck  der  Abwehr  von  Infektions- 
prozessen.     Miinchener  med.  W.,   1899,  Nos.  39  and  40. 

75.  Heinz,    Die    Wirkung   ausserer    (thermischer   und    chemi- 
scher) Reize  auf  die  Blutverteilung  in  der  Tiefe.    Verh.  d.  19.  Kon- 
gresses  f.  innere  Med.,   1901. 

76.  Wolter,  Ueber  das  Ferrum  candens  als  sogenanntes  Deri- 
vans.     Inaug.  Dissertation,  Bonn,  1873. 

77.  Schwering,  Ueber  das  Ferrum  candens.  Inaug.-Diss.,  Ber- 
lin, 1875. 

78.  Forchhammer,  Die  Finsentherapie  und  ihr  gegenwartiger 
Stand  in  der  Dermatologie.     Kopenhagen,- 1901,  and  7th  Kongress 
der  deutschen  Dermatologischen  Gesellschaft,  Breslau,  1901. 

79.  Paschutin,  Ueber  die  Absonderung  der  Lymphe  im  Arme 
des  Hundes.    Bericht  der  Konigl.  Sachs.  Ges.  d.  Wissensch.  Math, 
physik.  Klasse,  1873. 

80.  Emminghaus,  Ueber  die  Abhiinglichkeit  der  Lymphabson- 
derung   vom    Blutstrom.      Arbeiten    aus    der   physiol.    Anstalt  zu 
Leipzig,  1873. 


BIBLIOGRAPHIC   REFERENCES  233 

81.  Jankowsky,  Ueber  die  Bedeutung  der  Gefassnerven  fiir  die 
Entstehung  des  Oedems.     Virchow's  Archiv.  Vol.  93,  p.  259. 

82.  Rogowicz,  Beitrage  zur  Kenntnis  der  Lymphbildung.    Pflii- 
ger's  Archiv,  1885,  p.  252. 

83.  Pekelharing  and  Mensonides,  Cited  after  Virchow-Hirschs 
Jahresberichte,  1887.     The  original  was  inaccessible. 

84.  Chabbas.   Ueber  die   Sekretion  des  Humor  aqueus  in   Be- 
zug  auf  die   Ursachen   der  Lymphbildung.     Pfliiger's  Archiv,  Vol. 
16,  1878,  p.  143. 

85.  Leber,  Merkel-Bonnets  Ergebnisse  der  Anatomic  und  Ent- 
wickelungsgeschichte,  1894,  p.  156. 

86.  Emminghaus,    Physiologisches    und    Pathologisches    iiber 
die   Absonderung  der    Lymphe.     Wunderlich-Roser's  Archiv  der 
Heilkunde.  Vol.  15,  1874.  p.  369. 

87.  Tomsa,  Wiener  Sitzungsbericht,  Vol.  46,  Part  2.   Cited  after 
Paschutin.     The  original  was  not  accessible. 

88.  Gonitschewsky,  Ueber  Stauungsodem.     Virchow's  Archiv, 
Vol.  77,  p.  65. 

89.  Pugliese,  Beitrag  zur  Lehre  von  der  Lymphbildung.     Pflii- 
-ger's  Archiv,  1898,  Vol.  72,  p.  603. 

90.  Lassar,  Ueber  Oedem  und  Lymphstrom  bei  der  Entziin- 
dung.     Virchow's  Archiv,  Vol.  69,  p.  516. 

91.  Ritter,   Die  naturlichen  schmerzlindernden  Mittel  des  Or- 
ganismus.     Verh.    d.   deutschen   Ges.    f.   Chirurgie,   31.    Kongress, 
1902,  and  Archiv  f.  klinische   Chirurgie,   Vol.   68,   p.  429. 

92.  Notzel,  Ueber  die  baktericide  Wirkung  der  Stauungshype- 
ramie  nach  Bier.     Archiv  f.  klin.   Chirurgie,  Vol.  60,  Brochure  I, 
and  Verh.  der  deutschen  Gesellschaft  f.  Chirurgie,  28  Kongress, 
1899.  Vol.  2,  p.  661. 

93.  Buchner,  Ueber  die  naturlichen  Hilfskrafte  des  Organis- 
mus    gegeniiber  den    Krankheitserregern.     Miinchener   med.    W., 
1894,  No.  30. 

94.  Buchner.  Natiirliche  Schutzvorrichtungen  des  Organismus 
und  deren  Beeinflussung  zum  Zweck  der  Abwehr  von  Infektions- 
prozessen.  Miinch.  med.  W.,  1899,  Nos.  39  and  40,  and  Zur  Lehre 
von  der  naturlichen  Immunitat.    Miinch.  med.  W.,  1899,  No.  43. 

95.  Cornet,  Die  Tuberkulose.    In  Nothnagel's  specieller  Patho- 
logic und  Therapie,  Vienna,  1899,  pp.  545  and  546. 

96.  Richter.  Ueber  neuere  Behandlungsmethoden  der  Tuber- 
kulose.    Schmidt's  Jahrbiicher,  1893,  Vol.  239,  p.  180. 

97.  Hamburger,  Ueber   den   Einfluss  von   Kohlensaure  bezw. 
von  Alkali  auf  das  antibakterielle  Vermogen  von  Blut-  und  Ge- 
websfliissigkeit    mit     besonderer     Berucksichtigung   von    venoser 
Stauung  und  Entziindung.     Virchow's  Archiv,  Vol.  156,  Brochure 
2,  p.  329.  1899. 

98.  Hamburger,  Ueber  den  Einfluss  von  venoser  Stauung  und 
Kohlensaure   auf  die   Phagocytose.     Virchow's  Archiv,  Vol.    156. 
Brochure  2,  p.  375. 

99.  Spronk,  Weekblad  van  het  Nederl.  Tydschrift  vor  Genes- 
kunde,  1898,  No.  I.    The  original  contribution  was  not  accessible. 
I  know  it  only  from  a  citation. 


234  BIBLIOGRAPHIC   REFERENCES 

100.  Thiem,  Ueber  Thermotherapie  bei  der  Nachbehaudlung 
Unfallverletzter.  Zeitschr.  f.  Unfallheilkunde,  1900,  No.  3. 

101.  Traitement  des  lesions  tuberculeuses  accessibles  par  la  tem- 
perature elevee.     Report  of  the  French  Surgical  Congress  of  1891, 

102.  Wilson.     Hot  Air  in  Joint  Diseases.     Annals  of  Surgery, 
Vol.  29,  1899. 

103.  Lowenhardt,  Zur  Pathologic  und  Therapie  der  gonorrho- 
ischen  Gelenkserkrankungen.     Wiener  med.  Presse,  1898,  No.  45. 

104.  Ullmanri,  Wiener  klin.  W.,  1901,  No.  i. 

105.  S.  bei   C.   Ludwig,   Lehrbuch  der  Physiologic  des   Men- 
schen,  Vol.  2,  2nd  edition,  1861,  p.  565. 

106.  Orlow,  Einige*  Versuche  iibtr  die  Resorption  der  Bauch- 
hohle.     Pfliiger's  Archiv,  Vol.  59,  p.  170. 

107.  Heidenhain,  Bemerkungen  und  Versuche  betreffs  der  Re- 
sorption in  der  Bauchhohle.     Pfliiger's  Archiv,  Vol.  62,  p.  320. 

108.  Hamburger,  Ueber  die  Regelung  der  osmotischen  Spann- 
kraft  von  Fliissigkeiten  in  Bauch-  und  Pericardialhohle.     Du  Bois- 
Reymond-His'sches  Archiv,  Physiol.  Abt.,  1895,  p.  281. 

109.  Asher,  Ein  Beitrag  zur  Resorption  durch  die  Blutgefasse. 
Zeitschrift  f.  Biologic,  Vol.  29,  p.  247,  1892. 

110.  J.    Munk,    Zur   Kenntnis    der    instertitiellen     Resorption 
wasserloslicher  Substanzen.     Verh.  d.   Berliner  physiol.  Ges.   I2th 
session.  April  5,  1895.    DuBois-Reymond-His'sches  Archiv  Physiol. 
Abt.,  1895,  P.  387- 

in.  Klapp,  Ueber  Bauchfellresorption,  Mitteilungen  aus  den 
Grenzgebieten  der  Medizin  und  Chirurgie,  Vol.  10,  Brochures  i 
and  2. 

112.  Voit,  Untersuchungen  iiber  das  Verhalten  verschiedener 
Zuckerarten  im  menschlichen  Organismus  nach  subkutaner  Injek- 
tion.     Deutsches  Archiv  f.  klin.  Medizin,  Vol.  58.  p.  523. 

113.  v.  Recklinghausen,  Zur  Fettresorption.   Virchow's  Archiv, 
Vol.  26,  p.  172. 

114.  Wegner.  Chirurgische  Bemerkungen  iiber  die  Peritom:al- 
hohle  mit  besonderer  Beriicksichtigung  der  Ovariotomie.    Langen- 
beck's  Archiv,  Vol.  20. 

115.  Sulzer,  Ueber  den  Durchtritt  corpiiskularer  Gebilde  durch 
das  Zwerchfell.     Virchow's  Archiv,  Vol.  143,  p.  99. 

116.  Muscatello,    Ueber    den    Bau    und    das    Aufsaugungsver- 
inogen  des  Peritoneum.    Virchow's  Archiv.  Vol.  142,  p.  327. 

117.  Wolfler,  Ueber  den  Einfluss  der  Esmarchschen  Blutleere 
auf  die  Resorption  fliissiger  Stoffe.     Langenbeck's  Archiv,  Vol.  27. 

118.  Klapp,  Ueber  parenchymatose  Resorption.    Archiv  {.  ex- 
perimentelle  Pathologic  und  Pharmakologie,  Vol.  47,  p.  86. 

119.  Klapp,  Ueber  Bauchfellresorption.     Mitteilungen  aus  den 
Grenzg-ebieten  der  Medizin  und  Chirurgie,  Vol.   10,  Brochures   i 
and  2. 

120.  Sassetzky,  Ueber  den  Einfluss  erhohter  und  herabgesetz- 
ter  Temperaturen  auf   die   Resorption   an   der   Stelle   einer  subku- 
tanen  Injektion.    St.  Petersburger  med.  Wochenschrift,  1880,  Nos. 
15  and  19. 

121.  v.  Kossa,  Die  Resorption  der  Gifte  an  abgekiihlten  Kor- 


BIBLIOGRAPHIC   REFERENCES  235 

perstellen,  Archiv  f.  cxperimentelle  Pathologic  und  Pharmakolo- 
gie,  Vol.  36,  p.  120. 

122.  Hildebrandt,  Die  Ursachen  der  Heilwirkung  der  Lapara- 
tomie  bei   Bauchfelltubqrkulose.     Munch,  med.  W.,  1898. 

123.  Billroth,  Mancherlei  iiber  die  morphologisch«:n  Vorgange 
bei  der  Entziindung.     Med.  Jahrbiicher,  Vol.  18,  p.  18,  1860. 

124.  Leber,  Die  Entstehung  der  Entziindung.     Leipsic,   1891. 

125.  Buchner,  Natiirliche  Schutzeinrichtungen  des  Organismus 
und  deren  Beeinflussung  zum  Zweck  der  Abwehr  von  Infektions- 
prozessen.     Miinch.  med.  W.,  Nos.  39  and  40,  1899. 

126.  Landois,  Die  Transfusion  des  Blutes.     Leipsic,  1875. 

127.  Sudeck,  Ueber  die  akute  (reflektorische)  Knochenatrophie 
nach  Entziindungen  und  Verletzungen  an  den  Extremitaten  und 
ihre  klinischen  Erscheinungen.     Fortschritte  auf  dem  Gebiete  der 
Rontgenstrahlen,  Vol.  5. 

128.  Cited  in  Schmidt's  Jahrbiicher.  f 

129.  Berger,  Zur  Aetiologie  und  Pathologic  der  sogenannten 
Muskelhypertrophie.     Deutsches  Archiv  f.  klin.  Medizin,  Vol.  9, 

P.  363- 

130.  Lesage,  Note  sur  une  form  de  Myopathie  hypertrophique 
secondaire  a  la  fievre  typhoide.     Revue  de  medecine,  Vol.  8,  p. 
903.  1888. 

131.  Eulenburg,    Ein    Fall    von     fortschreitender    muskularer 
Dystrophie.     Deutsche  med.  W.,   1885,  p.   178. 

132.  Goldscheider,    Verhandl.   des    15.    Kongresses   fur  innere 
Medizin,  1897. 

133.  Masskow,     Muskelhypertrophie     nach     Venenthrombose. 
Inaug.  Diss.,  Berlin,  1897. 

134.  Auerbach,    Ein     Fall    von     wahrer     Muskelhypertrophie, 
Virchow's  Archiv,  Vol.  53,  pp.  234  and  397. 

135.  Redlich,   Ueber  einen  Fall  von   Hypertrophie  des  linken 
Beines,  Wiener  med.  Wochenschr.,   1893,  pp.   1482,  1519  and  1594. 

136.  Hitzig,     Ueber      einen     Fall     von     Hypertrophie     eines 
Armes.  Berliner  klin.  W.,  1872,  p.  588. 

137.  Oppenheim   and    Siemerling,    Ueber   das   Vorkommen   von 
Hypertrophie  der   Primitivfasern  in   Muskelpartikeln,  welche  dem 
lebenden    Menschen    excidiert   wurden.      Centralblatt   f.    die   med. 
Wissenschaften,  1889.  pp.  705  and  737. 

138.  Leber,  Die  Entstehung  der  Entziindung.     Leipsic,  1891, 
pp.  506,  163  and  164 

139.  Paget,  Lectures  on  Surgical  Pathology. 

140.  Stanley,   Treatise   on   Diseases   of  the    Bones.      London, 
1849. 

141.  Paget,   Lectures  on  Surgical   Pathology.     London,    1853, 
Vol.  i. 

142.  v.   Bergmann,   Ueb,er   die   pathologische    Langenzunahme 
der  Knochen.     St.  Petersburger  med.  Zeitschr.,  Vol.  14,  p.  65,  1868. 

143.  Helferich,  Ueber  die  nach  Nekrose  von  der  Diaphyse  der 
langen  Extremitatenknochen  auftretenden  Storungen  im  Langen- 
wachstum  derselben.     Deutsche  Zeitschrift  f.  Chirurgie,  Vol.   10, 
1878,  p.  324. 


236  BIBLIOGRAPHIC   REFERENCES 

144.  Langenbeck,    Ueber   krankhaftes     Langenwachstum     der 
Rohrenknochen  in  seiner  Verwertung  fur  die  chirurgische  Praxis. 
Berliner  kl.  W.,  1869,  p.  265. 

145.  Oilier,  Traite  experiment,  et  clinique  de  la  regeneration 
des  os.     Paris,  1867,  Vol.   i. 

146.  Schneider,   Ein    Beitrag  zur    organischen   Plastik  behufs 
Heilung  von  Unterschenkelgeschwuren.    Archiv  f.  klin.  Chirurgie, 
Vol.  9,  1868,  p.  919. 

147.      The    original :     Des    aneurysmes,    Paris,    1856,    was    not    ac- 
cessible. 

148.  Krause,    Traumatische    Angiektasie    des    !inken    Armes. 
Archiv  f.  klin.  Chirurgie,  Vol.  2,  1862,  p.  142. 

149.  Nicoladoni,  Phlebektasie  der  rechten  oberen  Extremitat. 
Archiv  fiir  klin.  Chirurgie,  Vol.  18,  p.  252. 

150.  Israel,   Angiektasie  im   Stromgebiete  der  Arteria  tibialis 
antica.     Archiv  f.  klin.  Chirurgie,  Vol.  21,  p.  109. 

151.  Hitzig,  Ueber  einen  Fall  von  Hypertrophie  eines  Armes. 
Berliner  klin.  W.,  1872,  p.  588. 

152.  H.  Fischer,  Der  Riesenwuchs.     Deutsche  Zeitschr.  f.  Chi- 
rurgie, Vol.   12,  p.  43. 

J53-  Oilier,  Des  moyens  d'augmenter  la  longeur  des  ps  et 
d'arreter  leur  accrissement;  application  des  donnees  experimen- 
tales  a  la  chirurgie.  Comptes  rendus  hebdominal  des  seances  de 
1'academie  des  sciences,  Paris,  1873. 

154.  Helferich,  Ueber  kiinstliche  Vermehrung  der  Knochen- 
neubildung.  Archiv  f.  klin.  Chirurgie,  Vol.  36,  p.  873,  1887. 

!55-  Schuller,  Mitteilung  iiber  die  kiinstliche  Steigerung  des 
Knochenwachstums  beim  Menschen.  Berliner  klin.  W.,  1889,  Nos. 
21  and  50. 

156.  Bidder,    Hypertrophy   des    Ohres    nach     Excision     eines 
Stiickes    vom    Halssympathicus    des    Kaninchens.       Centralbl.     f. 
Chirurgie,  1874,  p.  97. 

157.  Stirling,  Notes  on  the  effect  of  division  of  the  sympathetic 
nerve   of  the   neck  in  young  animals.     Journal   of   Anatomy   and 
Physiology,  Vol.  10,  1876,  p.  511. 

158.  Penzo,   Ueber  den  Einfluss  der  Temperatur  auf  die  Re- 
generation der  Zellen  mit  besonderer  Riicksicht  auf  die  Heilung 
der  Wunden.     Moleschott's  Untersuchungen  zur  Naturlehre,  1893, 
Vol.   15,   pp.    117-125. 

159.  Virchow,  Die  Cellularpathologie.     Berlin,  1858,  p.  113. 

1 60.  Cohnheim,  Allgemeine  Pathologic,  Vol.  I. 

161.  Cited  after  Roux,  Der  Kampf  der  Teile  im  Organismus. 
Leipsic,  1881. 

162.  Same. 

163.  Compare   among  others:   Cohn,   Klinik  der  embolischen 
Gefasskrankheiten,  Talma,  Der  Verschluss  der  Nierenarterie  und 
seine  Folgen.  Zeitschrift  f.  klin.  Med.,  Vol.  2,  p.  483. — Litten,  Ueber 
den  Einfluss  arterieller  Anamie  auf  die  Gefasswande.     Virchow's 
Archiv,  Vol.  88,  and  Untersuchungen  iiber  den  hamorrhagischen 
Infarkt  und   iiber   die    Einwirkung    arterieller    Anamie    auf    das 
lebende  Gewebe.     Zeitschr.  f.  klin.  Medizin,  Vol.  i,  p.  131.— Nico- 


BIBLIOGRAPHIC  REFERENCES  237 

lai,    Ueber   die    Ligatur    der    Nierengefasse.      Habilitationsschrift 
Kiel,  1895- 

164.  A  summary  of  the  views  concerned  will  be  found  in  the 
later  contributions  by  Kapsaiftmer:  Das  Verhalten  der  Knochen 
nach  Ischiadicusdurchschneidung.     Archiv  f.  klin.  Chirurgie,  Vol. 
56,  p.  348,  1898,  and  Muscatello  and  Damascelli:  Ueber  den  Ein- 
iluss  der  Nervendurchschuejdung  auf  die  Heilung  von  Knochen- 
briichen.     Archiv  f.  klin.  Chirurgie,  Vol.  58,  p.  937,  1899. 

165.  Nasse,   Ueber   den   Einfluss  der   Nervendurchschneidung 
auf  die  Ernahrung,  insbesondere  auf  die  Form  und  die  Zusammen- 
setzung  der  Knochen.    Pfliiger's  Archiv,  Vol.  23,  p.  361,  1880. 

166.  Samuel,  Das  Gewebswachstum  bei  Storungen  def  Inner- 
vation.     Virchow's  Archiv,  Vol.  113,  p.  272,  1888. 

167.  Bum,    Die    Entwickelung   des    Knochencallus   unter   dem 
Einflusse  der  Stauung,    Archiv  f.  klin.  Chirurgie,  Vol.  67,  p.  652, 
1902,  and  Experimentelle  Untersuchungen  uber  den  Einfluss  der 
Stauung   auf  die    Entwicklung   des    Knochencallus.     Centralbl.    f. 
Chirurgie,  1901,  No.  47. 

168.  Samuel,  Gewebswachstum  bei  Storungen  der  Blutzirkula- 
tion.     Virchow's  Archiv,  Vol.   108,  p.    I. 

169.  Beck,  Histologische  und  physiologische  Untersuchungen 
iiber  den  Heilungsprozess  der  Wunden,  uber  die  Bildung  und  Ura- 
wandlung  der  Exsudate  und  ihrer  mikroskopischen  Formelemente: 
Untersuchungen    und    Studien    auf   dem    Gebiete    der   Anatomic, 
Physiologic   und   Chirurgie,   Karlsruhe,    1852,   and   Joseph,    Ueber 
den  Einfluss  der  Nerven  auf  Ernahrung  und  Neubildung.     Archiv 
f.    Anatomic    Physiologic    u.    wissenschaftliche    Medizin,    1872,    p. 
206  (experiments  on  frogs). 

170.  Virchow,  Handbuch  der  speciellen  Pathologic  und  Thera- 
pie,  Vol.  I,  p.  274,  Erlangen,  1854. 

171.  Snellen,   Archiv   fiir   hollandische    Beitrage,     1857.      The 
original  was  not  accessible.    Cited  after  Samuel,  Virchow's  Archiv, 
Vol.  22.,  p.  405. 

172.  O.  Weber,  Die  Gewebserkrankungen  im  allgemeinen  und 
ihre    Ruckwirkung   auf   den    Gesamtorganismus.      Pitha-B«llroth's 
Handbuch  d.  Chirurgie,  Vol.  I,  p.  404,  1865. 

173.  Sinitzin,  Zur  Frage  iiber  den  Einfluss  des  Nervus  sympa- 
thicus  auf  das  Gesichtsorgan.     Centralblatt  fiir  die  med.  Wissen- 
schaften,  Vol.  9,  1871,  p.  161. 

174.  Eckhard,     Bemerkungen     zu     dem    Aufsatz    des     Herrn 
Sinitzin:  Zur  Frage  uber  den  Neryeneinfluss  des  Nervus  sympa- 
thicus    auf   das   Gesichtsorgan.      Centralblatt   f.   d.   med.    Wissen- 
schaften,  Vol.  II,   1873,  p.  547. 

175.  Senftleben,  Ueber  die  Ursachen  und  das  Wesen  der  nach 
der    Durchschneidung   des    Trigeminus     auftretenden     Hornhaut- 
affektion.     Virchow's  Archiv,  Vol.  65,  p.  69,  1875. 

176.  Danilewski,   Zur   Frage   iiber  den    Einfluss    der    aktiven 
Hyperamie   auf    Entziindungsprozesse    (Russian).      After  the   de- 
tailed citation  by  Anton  Schmidt  in  Centralbl.  f.  Chirurgie,  1883, 
P.  214. 

177.  Samuel,  Die  histogenetische  Energie  und  Symmetrie  des 
Gewebswachstums.    Virchow's  Archiv,  Vol.  101,  p.  389. 


238  BIBLIOGRAPHIC   REFERENCES 

178.  Samuel,  Ueber  anamische,  hyperiimische  und  neurotische 
Entziindungen.     Virchow's  Archiv,  Vol.  121,  p.  396,  1890. 

179.  Liek,  Ueber  den  Einfluss  der  Temperatur  auf  die  Regene- 
ration der  Zellen  mit  besonderer  Rucksicht  auf  die  Heilung  der 
Wunden.     Moleschott's  Untersuchungen  zur  Naturlehre  des  Men- 
schen  und  der  Tiere,  Vol.  15,  p.  107,  1895. 

179.     Liek,  Ueber  den  Einfluss  der  arteriellen   Hyperamie  auf 
die  Regeneration.    Archiv  f.  klin.  Chirurgie,  Vol.  67,  p.  229. 

181.  Guyot,  De  1'emploi  de  la  chaleur,  Paris,  1842.     Cited  after 
Bardeleben,  Lehrbuch  der  Chirurgie,  5th  edition,  Vol.  i,  p.  113. 

182.  Ritter,    Die    Behandlung    der     Erfrierungen.      Deutsche 
Zeitschr.  f.  Chirurgie,  Vol.  58,  p.   172. 

183.  Bonnet,      Weitere    .  Mitteilungen     uber     Embryotrophe. 
Deutsche  med.  W.,  1902,  No.  30. 

184.  Weigert,    Neue    Fragestellungen    in    der    pathologischen 
Anatomic.      Gesellschaft    deutscher    Natwforscher     und     Aerzte. 
Verh.,  1896,  Allgemeiner  Teil. 

185.  H.  Schulz,  Pharmakotherapie  im  Lehrbuch  der  allgemei- 
nen  Therapie  von  Eulenburg  und  Samuel. 

186.  Uebersicht    uber    die    Ergebnisse    der    med.     Klinik     zu 
Breslau.    Wiener  med.  W.,  1853,  No.  53,  p.  635. 

187.  Medizinische    Jahrbiicher    des     k.     k.     Oesterreichischen 
Staates,  Vol.  26,  or  of  the  new  series  Vol.  17,  Vienna,  1838,  p.  417. 

188.  Lebert,  Ueber  den  Einfluss  der  Stenose  des  Conus  arte- 
riosus,  des  Ostium  pulmonale,  und  der  Pulmonalarterie  auf  Ent- 
stehung  von  Tuberkulose.  Berliner  klin.  W.,  1867,  Nps.  22  and  23. 

189.  Eymann,  Ueber  die  Kombination  von  Phthise  und  Herz- 
fehler,  Inaug.-Diss.,  Wurztfurg,  1886. 

190.  B.   Schultze,   Beitrag  zur   Statistik   der  Tuberkulose   ver- 
bunden  mit    Herzklappenerkrankungen.     Inaug.-Diss.,   Kiel,    1891. 

191.  Frommolt,     Ueber    das     gleichzeitige    Vorkommen    von 
Herzklappenfehlern   und    Lungenschwindsucht.     Archiv    f.     Heil- 
kunde,  1875,  No.  12. 

192.  Bamberger,    Lehrbuch    der    Krankheiten     des     Herzens. 
Vienna,  1875,  p.  204. 

193.  Traube,  Gesammelte  Beitrage  zur  Physiologic  und  Physio- 
logic, Vol.  2,  No.  47,  p.  748. 

194.  Dusch,    Lehrbuch    der    Herzkrankheiten.      Leipsic,    1868, 
p.  185. 

195.  Ruhle,  Die  Lungenschwindsucht,  v.  Ziemssens  Handbuch, 
Vol.  5,  2nd  edition,  part  2,  p.  35. 

196.  Stalherm,   Ueber  Kyphose  und  ihre  Beziehungen  zu  den 
Veranderungen  der  inneren  Organe.     Inaug.-Diss.,  Kiel,  1892. 

197.  Rokitansky,  Lehrbuch  der  pathologischen  Anatomic,  Vol. 
2,  Vienna,  1856. 

198.  v.   Kryger,  Das   gleichzeitige  Vorkommen  von   Lungen- 
tuberkulose  und  Klappenfehler  des  linken  Herzens.     Inaug.-Diss., 
Munich,  1889. 

199.  Otto,  Virchow's  Archiv,  Vol.  144. 

200.  Burwinkel,  Chronische  Herz-  und  Lungenleiden  in  ihren 
Wecheselbeziehungen.    Deutsche  Medicinalztg,  1902,  No.  34. 

201.  Bier,   Ueber  ein  neues  Vgrfahren  der  conservativen  Be- 


BIBLIOGRAPHIC  REFERENCES  239 

handlung    von    Gelenktuberculose    Verb,    der    deutschen    Ges.    f. 
Chirurgie,  1892,  Vol.  i,  p.  91. 

202.  Behandlung   chirurgischer   Tuberkulose   der  Gliedmassen 
mit  Stauungshyperamie.    v.  Esmarch's  Festschrift,  Kiel  and  Leip- 
sic,   1893,  P-  54- 

203.  Weitere  Mitteilungen  iiber  die  Behandlung  chi-rurgischer 
Tuberkulose  mit  Stauungshyperamie.     Verb.  d.  deutschen  Ges.  f. 
Chirurgie,  1894,  vol.  2,  p.  94,  and  Archiv  f.  klin.  Chirurgie,  1894. 

204.  Behandlung  der  Gelenktuberkulose  mit  Stauungshypera- 
mie.    Berliner  Klinik,  November,  1895. 

205.  Jacoby,  Munch,  med.  W.,  1897,  Nos.  8  and  9,  and  Verb, 
des  Kongresses  fur  inrrere   Medizin. 

206.  Blecher.  Ueber  den  Einfluss  der  kiinstlichen  Blutstauung 
auf  Gelenksteifigkeiten  nach  Trauma  und  langerer  Immobilisation. 
Deutsche   Zeitsehr.   f.   Chirurgie,  Vol.  60. 

207.  Klapp,  Behandlung  von  Gelenkergiissen  mit  heisser  Luft. 
Munch,  med.  \V..  1900. 

208.  Schaffer,  Die  Behandlung  von  Gelenkergiissen  mit  heisser 
Luft.     Inaug.-Diss.,  Greifswald,  1902. 

209.  Bier,  Ueber  den  Einfluss  kiinstlich  erzeugter  Hyperamie 
des    Gehirns   und   kiinstlich    erzeugten    Hirndrucks    auf   Epilepsie, 
Chorea  u.   s.   w.     Grenzgebiete   der  Medizin  und   Chirurgie,   1900, 
Vol.  7. 

210.  1.  c.  and  Dei'tsche  med.  Wochenschrift,  1899,  No.  31. 


Date  Due 


IN  U.  S.  A. 


3   1970  00592  3773 


A    000510471     6 


